what is the degree of this burn?

what is the degree of this burn?
what is the management?
what is the prognosis?

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Evaluation and Management of Abnormal Uterine Bleeding in Premenopausal Women

harmacologic Treatment of Abnormal Uterine Bleeding

Medication	Dosage	Cost of generic (brand)[*]	Comments
Anovulatory bleeding
Combination oral contraceptives[4]	≤ 35 mcg of ethinyl estradiol monophasic or triphasic pills	NA ($9 to 92)	Provides contraception Contraindications include smokers older than 35 years, personal history or high risk of deep venous thrombosis or pulmonary embolism, multiple risk factors for arterial cardiovascular disease, history of breast cancer, and severe cirrhosis or liver cancer[33]
Medroxyprogesterone acetate (Provera)[9]	10 mg per day for 10 to 14 days per month	$13 ($38)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Endometrial hyperplasia without atypia
Medroxyprogesterone acetate[14]	10 mg per day for 14 days per month	$13 ($38)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Megestrol (Megace)[11]	40 mg per day	$25 (NA as tablets)	Does not provide contraception Caution in patients with severe hepatic dysfunction
Levonorgestrel-releasing intrauterine system (Mirena)[31]	Releases 20 mcg per 24 hours	NA ($562[‡])	96 percent regression rate for hyperplasia without atypia[31] Provides contraception for five years May cause irregular bleeding or amenorrhea Contraindications include breast cancer; uterine anomaly that distorts the cavity; acute pelvic or cervical infection; and severe cirrhosis or liver cancer[33] More expensive initially, but similar to other therapies when averaged over five years

Ovulatory bleeding
Levonorgestrel-releasing intrauterine system [34] , [35]	Releases 20 mcg per 24 hours	NA ($562[‡])	FDA-approved for menorrhagia in 2009; see additional comments above
Medroxyprogesterone acetate[34]	10 mg per day for 21 days per month	$16 ($40)	Does not provide contraception Effective short-term therapy for decreasing heavy flow Not tolerated as well long term as levonorgestrel-releasing intrauterine system Caution in patients with severe hepatic dysfunction
NSAIDs [36] , [37]
Ibuprofen	600 to 1,200 mg per day, five days per month	$4 ($16)	Begin first day of menses and continue for five days or until menses ceases Treats dysmenorrhea
Naproxen sodium (Anaprox)	550 to 1,100 mg per day, five days per month	$4 ($50)	Caution in patients with gastrointestinal risks
Mefenamic acid (Ponstel)	1,500 mg per day, five days per month	$429 ($553)
Tranexamic acid (Lysteda) [38] , [39]	650 mg; two tablets three times per day, five days per month	NA ($170)	FDA-approved for menorrhagia in 2009 Begin first day of menses and continue for five days [38] , [39]  Caution in patients with history or risk of thromboembolic or renal disease Contraindicated if patient has active intravascular clotting or subarachnoid hemorrhage Considerably more expensive than other available therapies

Osteoarthritis: Diagnosis and Treatment

Osteoarthritis is a common degenerative disorder of the articular cartilage associated with hypertrophie bone changes. Risk factors include genetics, female sex, past trauma, advancing age, and obesity. The diagnosis is based on a history of joint pain worsened by movement, which can lead to disability in activities of daily living. Plain radiography may help in the diagnosis, but laboratory testing usually does not. Pharmacologic treatment should begin with acetaminophen and step up to nonsteroidal anti-inflammatory drugs. Exercise is a useful adjunct to treatment and has been shown to reduce pain and disability. The supplements glucosamine and chondroitin can be used for moderate to severe osteoarthritis when taken in combination. Corticosteroid injections provide inexpensive, short-term (four to eight weeks) relief of osteoarthritic flare-ups of the knee, whereas hyaluronic acid injections are more expensive but can maintain symptom improvement for longer periods. Total joint replacement of the hip, knee, or shoulder is recommended for patients with chronic pain and disability despite maximal medical therapy

- Signs and Symptoms of Osteoarthritis

Hand Pain on range of motion Hypertrophic changes at distal and proximal interphalangeal joints (Heberden nodes and Bouchard nodes; Figure 1) Tenderness over metacarpophalangeal joint of thumb

Shoulder Pain on range of motion Limitation of range of motion, especially external rotation Crepitus on range of motion

Knee Pain on range of motion Joint effusion Crepitus on range of motion Presence of popliteal cyst (Baker cyst) Lateral instability Valgus or varus deformity

Hip Pain on range of motion Pain in buttock Limitation of range of motion, especially internal rotation

Foot Pain on ambulation, especially at first metatarsophalangeal joint Limited range of motion of first metatarsophalangeal joint, hallux rigidus Hallux valgus deformity

Spine Pain on range of motion Limitation of range of motion Lower extremity sensory loss, reflex loss, motor weakness caused by nerve root impingement Pseudoclaudication caused by spinal stenosis

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
Physical therapy using land-based or water-based exercise can help reduce pain and improve function in patients with osteoarthritis	B	[10] , [11] ,[12]
Acetaminophen should be used as first-line therapy for mild osteoarthritis.	A	16
Nonsteroidal anti-inflammatory drugs are superior to acetaminophen for treating moderate to severe osteoarthritis	A	16
Intra-articular corticosteroid injections can be beneficial for short-term (i.e., less than eight weeks) relief of osteoarthritis pain of the knee.	A	[21] , [22]
Compared with intra-articular corticosteroids, intra-articular hyaluronic acid njections of the knee are less effective in the short term, equivalent in the ntermediate term (i.e., four to eight weeks), and superior in the long term	B	[26] , [27]
The combination of glucosamine and chondroitin may decrease pain in patients with moderate to severe knee osteoarthritis, although the evidence for this effect is limited and inconsistent.	B	30
Patients who have continued pain and disability from osteoarthritis of the hip, knee, or shoulder despite maximal medical therapy are candidates for total joint replacement.

Complementary and Alternative Medicine

A meta-analysis on the effectiveness of acupuncture for osteoarthritis of the knee found only short-term benefit, which the authors described as clinically irrelevant.^[28] Acupuncture can be of benefit in chronic low back pain, but studies do not differentiate the etiology of the back pain.^[29]

The most widely used supplements for osteoarthritis are glucosamine and chondroitin. The literature consisted of small clinical trials until the release of the Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), which included more than 1,500 patients. The trial had five arms comparing glucosamine alone, chondroitin alone, a combination of glucosamine and chondroitin, celecoxib, and placebo. The results were favorable only for the combination of glucosamine and chondroitin, which appeared to be effective for moderate to severe osteoarthritis of the knee.^[30] Chondroitin alone did not show benefit for osteoarthritis of the knee or hip in a meta-analysis.^[31]

Balneotherapy is a heterogeneous group of treatments also known as spa therapy or mineral baths. A Cochrane review concluded that mineral baths were of some benefit to patients with osteoarthritis, but the authors addressed methodologic flaws in the studies and urged caution in interpreting the findings.^[32] Capsaicin cream is a topical analgesic derived from chili peppers. It has been found to be superior to placebo in treating osteoarthritis pain. It is widely available, is relatively inexpensive, and can be used as an adjunct to standard osteoarthritis treatments.^[33] There also is evidence supporting the use of the supplement S-adenosylmethionine (SAM-e) to reduce functional limitation, but not compared with placebo in patients with osteoarthritis pain. The effectiveness of SAM-e is comparable to that of NSAIDs in some studies but with fewer adverse effects.^[34]

Surgical

Surgery should be reserved for patients whose symptoms have not responded to other treatments. The well-accepted indication for surgery is continued pain and disability despite conservative treatment. The most effective surgical intervention is total joint replacement, with excellent patient outcomes following total joint replacement of the hip, knee, and shoulder. ^[1] , [35] Many different prosthetic devices are available; however, controlled trials comparing the various devices are lacking. Patients can expect that most current joint prostheses will function well for 15 to 20 years.^[35]

There are other surgical approaches to osteoarthritis treatment, but they have not equaled the success of total joint replacement. Randomized trials of arthroscopic debridement for osteoarthritis of the knee have consistently failed to show an advantage over maximal medical therapy combined with physical therapy.^[36]

IBS

Diagnostic Criteria for IBS

Abdominal discomfort or pain, for at least 12 weeks (which need not be consecutive) in the preceding 12 months, with two of the following features:
	Relief with defecation
	Onset associated with a change in stool frequency
	Onset associated with a change in form or appearance of stool
These additional symptoms cumulatively support the diagnosis of IBS:
	Abnormal stool frequency (more than three times per day or less than three times per week)
	Abnormal stool form (loose and watery or lumpy and hard)
	Abnormal stool passage (urgency, frequency, feeling of incomplete evacuation)
Passage of mucus (white material)
Bloating or sensation of abdominal distention

Signs and Symptoms Suggesting Alternative Diagnosis to Irritable Bowel Syndrome

Sign or symptoms	Suggested diagnosis
Alarm factors
Anemia	Cancer, IBD
Chronic severe diarrhea	Cancer, infection, IBD
Family history of colon cancer	Cancer
Hematochezia, melena, or other signs of intestinal bleeding	Cancer, arteriovenous malformation, colonic polyps, IBD
Recurrent fever	Infection, IBD
Weight loss	Cancer, IBD
Other signs and symptoms
Travel to areas with parasitic diseases	Infection
Family history of colon cancer, irritable bowel syndrome, celiac disease	Cancer, celiac disease
Signs or symptoms of malabsorption	Celiac disease
Nighttime symptoms (e.g., encopresis)	Infection, trauma
Onset after 50 years of age	Cancer
Arthritis	Arthritis
Thyroid dysfunction

Medications for Treatment of Irritable Bowel Syndrome

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Treatment	Initial dosage	Maintenance dosage	Cost (generic)*	Comments
Dicyclomine (Bentyl)	20 mg fourtimes per day	20 to 40 mg four times per day	$63 (22 to 82)	If not effective in two weeks, discontinue.
Hyoscyamine (Levsin)	0.125 to 0.250 mg every four hours	Same	145 (52 to 61)	Anticholinergic effects; maximum 1.5 gm per day
Loperamide (Imodium)	4 mg	4 to 8 mg per day	49 (15 to 42)	—
Amitriptyline	10 to 25 mg every night at bedtime	10 to 100 mg every night at bedtime	8 (2 to 10)	Large dosing range; start low, and titrate as needed.
Desipramine (Norpramin)	10 to 50 mg every night at bedtime	10 to 150 mg every night at bedtime	21 (12 to 21)	Large dosing range; start low, and titrate as needed.
Alosetron (Lotronex)	1 mg per day for four weeks	1 mg once or twice per day	216	Use in women with diarrheapredominant irritable bowel syndrome; use with caution; available only through prescribing program; associated with ischemic colitis.
Tegaserod (Zelnorm)	6 mg twice per day for four to 12 weeks	Same	169	Use in constipation with same caveats as alosetron; only indicated for 12 weeks of therapy.