Professor of Anesthesiology, Physiology, and Pharmacology
Drexel University College of Medicine
Professor of Epidemiology and Biostatistics
Drexel University School of Public Health
Philadelphia, Pennsylvania
Think about what you might encounter: communication skills assessments usually use simulated patients who may respond in a number of ways arthritis medication for dogs buy 400mg plaquenil with mastercard. For example arthritis in knee operation order plaquenil 200 mg without a prescription, how will you deal with an emotional patient rheumatoid arthritis lyme disease generic 200mg plaquenil visa, a non-communicative patient or an angry response to breaking bad news Listen to the examiner: if you are asked to present and discuss the case arthritis in lower back diagnosis discount plaquenil 200 mg line, listen carefully to the examiner and present the salient features in a clear and logical manner. Preparation and planning, listening to the patient, delivering information in small amounts with regular checking and allowing time for information to be assimilated and for questioning are paramount. Closure is also important, ensuring the patient knows what is happening and is clear about the next steps. Assessment of communication skills Clinical competence is assessed at all levels of medical education. Students and trainees attempting these assessments should have been through appropriate 6 the medical interview Concrete experience Consultation with a patient Interview a simulated patient Role play Active experimentation Try a different approach in a learning environment Reflection Think about the consultation Observe a recorded consultation Give and receive feedback Abstract conceptualisation What will I do differently next time The cycle enables the learner to build on existing knowledge and skills, to take responsibility for their own progress and to use real life clinical and simulated encounters to promote further learning. Introduction General examination can reveal abnormalities in a number of systems which may assist in making an accurate diagnosis. Disorders of gait, speech and mood should be apparent on first meeting the patient and during the consultation process. Dyspnoea may be observed and abnormal movements, including tremor or paucity of facial expression, should be noted. During the general examination, obvious features of systemic disease in one site should be correlated with signs elsewhere. General examination 9 Rheumatological system Axillae With shoulders relaxed examine. Many patients with ischaemic heart disease have few or no physical signs and a characteristic history of peripheral vascular disease may be elicited. Systematic and thorough examination of the cardiovascular system is a core skill for physicians. Accurate assessment of peripheral cardiovascular signs aids the interpretation of auscultatory findings. Patients with ischaemic heart disease may have few physical signs and physicians should be aware of the likely sites and significance of scars from previous surgical or radiological intervention. Cardiac valvular disease and septal defects usually give rise to murmurs which may be diagnostic. Cough: Oedema: the vertical height of the top of the column of blood above the sternal angle. Family history: Suspect a low level: unless the liver is tender, press on the abdomen gently but firmly. Check if the ear lobes move with the cardiac cycle and sit the patient vertically to get a greater length of visible jugular vein above the right atrium. Use the bell of the stethoscope to examine lowpitched noises, especially diastolic murmurs at the apex, and the diaphragm to examine high-pitched noises and the precordium generally. Palpate the right carotid artery when auscultating to identify the stages of the cardiac cycle. Ask the patient to roll onto their left side and listen over the apex to accentuate mitral murmurs and check their radiation. Ask the patient to sit up, lean forwards and hold their breath in expiration to listen for aortic diastolic murmurs. Pulsatile Jugular vein fills and empties Cardiovascular system 13 Internal jugular vein External jugular vein Systolic clicks: occur in early or mid-systole; indicate aortic or pulmonary stenosis, mitral valve prolapse and prosthetic heart valves. Pericardial friction rub: low-pitched and scratchy; heard over the lower sternum; varies with posture and breathing. First heart sound (S1): occurs at the onset of systole when mitral and tricuspid valves close; loud in hyperdynamic circulation and mitral stenosis, soft in heart failure and mitral regurgitation. Second heart sound (S2): occurs at the end of systole when aortic and pulmonary valves close; split on inspiration (A2 then P2); fixed splitting in atrial septal defect; variable splitting with bundle branch blocks. Fourth heart sound (S4): occurs at the end of diastole before S1; present in severe left ventricular hypertrophy and aortic stenosis. Specific features in the history of a patient with hypertension are shown in Box 3. Mild or moderate hypertension usually produces no abnormalities on physical examination other than raised blood pressure. Renal artery stenosis: renal artery bruit in the epigastrium Polycystic kidney disease Other forms of chronic kidney disease Coarctation of the aorta: radial-femoral arterial pulse delay, weak femoral pulses, bruits of the coarctation and of the scapular anastomoses, visible pulsation of the anastomoses. Cushing syndrome acromegaly Phaeochromocytoma and primary hyperaldosteronism (Conn syndrome) have no specific features on physical examination. Best heard with patient sitting forwards in expiration Mid or late rumbling diastolic murmur at apex; presystolic accentuation if sinus rhythm. Look for signs of coexistent connective tissue or other disorders Turn patient on left side (and exercise) to accentuate murmur. Often atrial fibrillation Radiation to axilla; often heard parasternally Usually benign. If the rate is less than 60/min the patient has a bradycardia; if greater than 100/min, a tachycardia. Use the edge of a piece of paper to mark off a series of R waves, and then shift the paper along one or more complexes. The marks on the paper will still correspond with the R waves if the rhythm is regular. To gain a rough idea of the axis, find the limb lead with the maximum net positive deflection (sum of the positive R wave and negative Q and S waves); the axis lies close to this. Peripheral vascular system Patients with peripheral vascular disease may complain of. Whilst simple radiography, measurement of oxygen saturation and blood gas analysis are available in the majority of emergency clinical settings, the mainstay of diagnosis remains the clinical assessment. In chronic lung disease, the availability of sophisticated radiology and respiratory physiology can be used to confirm the diagnosis and monitor disease progress. Examine the front and back of the chest in a logical manner, usually by palpating, percussing and auscultating the front of the chest first, followed by the rear. When examining the back of the chest, ask the patient to put their hands on their hips to facilitate examination of the lung bases laterally. Examination Key abnormalities detected on examination of the chest are shown in Table 4. The position of the heart apex beat is of no help in assessing lung disease except if there is marked mediastinal shift. Patients who have more than one small haemoptysis should be referred for bronchoscopy. Clubbing Finger clubbing is associated with a range of respiratory diseases, but also with disease in the cardiovascular and gastrointestinal systems. Investigation of haemoptysis the usual clinical problem is to exclude carcinoma and tuberculosis. A full history and clinical examination will usually identify pulmonary infarction, foreign body, bronchiectasis, mitral stenosis and pulmonary oedema. Oblique fissures run along the line of the fifth/ sixth rib; a horizontal fissure runs from the fourth costal cartilage to the sixth rib in the mid-axillary line. Anteriorly you are listening mainly to upper lobes and on the right the middle lobe. Central cyanosis is usually caused by the presence of an excess of reduced haemoglobin in the capillaries. Left ventricular failure may produce cyanosis that is partly central (pulmonary) and partly peripheral (poor peripheral circulation). A rare cause of cyanosis, not caused by increased circulating reduced haemoglobin, is the presence of methaemoglobin (and/or sulphaemoglobin).
Evaluating the relationship between breakfast pattem and short-term memory Pak J 5 upp I e net t s rheumatoid arthritis types buy 200mg plaquenil visa. Types and Sources Simple Carbohydrates: small sugar molecules that are sweet to the taste rheumatoid arthritis xanax discount plaquenil 400mg amex. Complex Carbohydrates: contain many glucose molecules (and sometimes other sugars) that are linked together relief arthritis jaw purchase 200 mg plaquenil overnight delivery. Glycogen: a storage form of glucose in the liver and muscles making glucose readily available when needed (only found in foods of animal origin) C arthritis in end of fingers buy plaquenil 200mg with visa. Fiber: structural parts of plants that contain bonds between the simple sugars that cannot be broken down by digestive enzymes. Are the most abundant and economical source of energy for the body Spare proteins from being burned for energy Are needed in the metabolism of fat Primary source of energy for brain cells Excess glucose is stored as fat and glycogen for later energy release Precursors for: molecular parts of cells. Excess glucose is stored as glycogen in the liver and muscles for quick energy releaser Carbohydrates (once they are broken down to glucose) are responsible for keeping up the blood sugar level. Complex carbohydrates are gradually broken down into simple sugars (glucose) throughout the digestive tract. Consequently, complex carbohydrates should be the primary form of carbohydrate ingestion. This is very inefficient and produces a significant amount of waste that the body needs to rid itself of. When fat is used as the primary energy source fat fragments combine to form ketone bodies. When the production of ketone bodies exceed their use they accumulate in the blood causing a potentially life-threatening condition called ketosis. Some of the adverse effects of low-carbohydrate diets include: nausea, fatigue, constipation. Refined Sugar Refined sugar is any sugar that is removed from the plant in which it naturally occurred. Juice is partially refined; table sugar is totally refined; honey is refined by honeybees. The following figures demonstrate how the use of sugar and other sweeteners has increased dramatically from 1822 to the present. When a person ate no sugar, it was found that each white blood cell could destroy 14 bacteria in 30 minutes. When l8 teaspoons were ingested (1 1/" sodas) the number of bacteria destroyed in 30 minutes dropped to only 2. The less sugar introduced into the food in its preparation the less difficulty will be experienced because of the heat of the climate. Whole grains and legumes are the highest in fiber; fruits and vegetables contain moderate fiber; polished grains and juices contain almost no fiber; and animal products. Current Daily Recommended Intake suggests consuming l4 grams of fiber for every 1. Soluble Fiber: Soluble (can be dissolved) in water but not digestible by human digestive system. Decreases rate of gastric emptying and slows absorption of simple sugars in small intestine (due to entrapment in soluble fibers. This stabilizes the blood sugar curves and helps to avoid sudden "highs" and "lows" in the. Helps to lower cholesterol by binding bile (which contain cholesterol) in the small intestines. Insoluble Fiber: Not soluble in water; not digestible by the human digestive system. Holds water-increases stool bul[reduces elevated pressure in walls of the colon (reduces risk of colon cancer, constipation. Many governments require that their commercially processed grains are enriched with 4-5 nutrients. This makes enriched rice and flour more nutritious than simply refined flour, but whole grain products would contain many more vitamins and minerals essential for health. Refined grains also suffer from the lack of dietary fiber which is needed for good health. Eff-ect of sex hormones on non-esterified fatty acids, intra-abdominal fat accumulation, and hypertension induced by sucrose diet in male rats. Cell membrane component Used in the formation of hormones Necessary for absorption of fat-soluble vitamins Insulation against temperature extremes (in form of layer of fat beneath the skin) Protection (padding from mechanical shock) Energy source for the body Supplies essential nutrients (fatty acids) Improve flavor. The amount of fat we utilize depends on: Age and metabolism - A child burns energy faster than an older person and therefore needs more fat. Activity level - People who work very hard physically or are very active can use more fat. Excess l Obesity: Fats are a concentrated source ofcalories and are easy to store in the body. Saturated fats are composed ofcarbon chains "saturated" with hydrogen (they cannot hold any more hydrogen). Based upon its very high saturated fat content (92%), coconut oil is expected to significantly increase blood cholesterol levels. While many of the earlier studies used regular coconut oil and observed a sharp elevation of blood cholesterol levels. This is explained by the rich content of polyphenolic antioxidants in the virgin oil. Regular coconut oil comes from extraction of the dried coconut meat (copra) and is typically bleached, deodorized, and refined. These fats have one or more places in which hydrogen atoms are missing and the adjacent carbon atoms are bonded together in a "double bond. Most oils contain a combination of monounsaturated, polyunsaturated, and saturated fatty acids, but are labeled according to the predominate type of fat they contain. Liquid at room temperature and in the refrigerator6 Easily combines with oxygen (oxidize) to become rancid6 Common Sources: Nuts. The body can make all of these except for Omega-6 and Omega-3 polyunsaturated fatty acids, which must be obtained from the diet. They tend to decrease cholesterol and serum triglycerides (fats in bloodstream) 6. Cholesterol (a sterol) include: is a white, waxy fat which is manufactured by the body. Our liver manufactures sufficient cholesterol for human needs from the foods we eat. Atherosclerosis (plaque build-up associated with hardening of the blood vessel) 3. Poor circulation due to clogging by plaque (peripheral artery disease, intermittent claudication. None from our diet, since the human body produces all the cholesterol needed to meet its daily needs. However" there is one fraction of cholesterol that removes the unhealthy cholesterol from the vessels. The advantages sought by the use of butter may be obtained by the eating of properly prepared olives. Frying is never ideal for the health since toxic byproducts are routinely produced; however, if fat will be utilized for frying, refined oils (especially high oleic oils) which contain fewer essential fatty acids are safer as they produce less toxic byproducts. Typical frying temperatures run around 190 degrees C, and the quality of the oil deteriorates each time it is reused for frying. Other healthier alternatives used in some cultures around the world include placing a little water in the pan and then adding the oil. Lung Cancer in Chinese Women: the lung cancer incidence in Chinese women is among the highest in the world. Several cooking oils were heated in a wok to boiling, at temperatures ranged from 240-280 degrees C (typical cooking temperatures in China). The oils tested were unrefined Chinese rapeseed, refined rapeseed (known as canola), Chinese soybean, and Chinese peanut oils.
The developer solution arthritis fingers bowling cheap 200 mg plaquenil free shipping, particularly the hydroquinone arthritis knee lose weight purchase plaquenil 200 mg without a prescription, is especially sensitive to oxygen arthritis in fingers wiki generic plaquenil 200mg on line. The preservative arthritis eye pain plaquenil 400 mg, sodium sulfite or cycon, is added to the developer to prevent its rapid oxidation. The solvent for the concentrated chemicals is water, used to dilute the concentrate to the proper strength. Rapid processing is achieved through the use of high temperatures that accelerate the development process; however, high temperatures can cause excessive emulsion swelling. Because excessive swelling can result in roller transportation problems, a hardener, traditionally glutaraldehyde, is added to the developer to control the amount of emulsion swelling. A restrainer, or antifog agent, is added to the developer to limit its activity to only the exposed silver crystals. Without the restrainer, the developing agents would attack the unexposed crystals, creating chemical fog. Potassium bromide is frequently referred to as "starter solution" because it is added only to fresh, new developer. As films are developed, bromine ions are released from the emulsion into solution; thus, potassium bromide is not found in replenisher solution. The function of the fixer (hypo) is to clear the film of the unexposed, undeveloped silver bromide crystals. The fixer is an acidic solution that functions to neutralize any residual developer carried over and provide the required acid medium for the hardener. The fixer contains a hardener whose function is to shrink and reharden the gelatin emulsion, thus protecting it from abrasion and promoting archival quality. Fixer preservative is the same as that found in the developer, that is, sodium sulfite. Since radiographic records are kept for a number of years, it is important that they have sufficient archival quality. Cold-water processors are, in general, less efficient in removing chemicals than warm-water processors, but the cold water helps maintain proper developer temperature. Agitation during the wash process and large quantities of water help rid the emulsion of chemical residue. The development process is greatly affected by development time and solution temperature and activity. Sodium or potassium carbonate provides the necessary alkalinity and functions as the solution activator by swelling the gelatin emulsion. Sodium sulfite or cycon preserves the developer solution from excessive oxidation. Potassium bromide serves as an antifog agent and restrains the developer from attacking the unexposed silver bromide crystals. Potassium bromide is starter solution and is not required in replenisher solution. The fixing or clearing agent (ammonium thiosulfate) removes unexposed silver bromide crystals from the emulsion, preventing further exposure. Adequate washing of residual chemicals from the film emulsion is essential for good archival quality. This is accomplished without damage to the film and at a prescribed speed, which determines the length of time film spends in each solution. The roller system also provides constant, vigorous agitation of the solution at the film surface. The entire conveyance system consists of the feed tray, crossover rollers, deep racks, turnaround assemblies, and receiving bin. Film is aligned against one side of the feed tray as it is introduced into the processor. A sensor initiates solution replenishment as the film enters, and replenishment continues as the length of the film passes the sensor. Films should be fed into the processor along their short edge; feeding the film in "the long way" leads to overreplenishment and increased radiographic density. Crossover rollers must be kept free of crystallized solutions that can cause film artifacts as the soft emulsion passes by. When the processor is not in use for a period of time, it is advisable to leave the lid open so that moisture can escape. Because the crossover rollers are out of solution, chemicals carried onto them by film can crystallize and should be cleaned off before the processor is used again. Turnaround assemblies are located at the bottom of the deep racks and serve to change the film direction as it changes from downward to upward motion. Guide shoes, or deflector plates, are also located where film must change direction. They will occasionally scratch film, leaving characteristic guide-shoe marks, when they require adjustment. When returning rollers to the processor after cleaning, care must be taken to seat them securely in their proper position. It is the function of the processor replenishment system to keep solution tanks full. If solution level is allowed to lower, film immersion time decreases and radiographic density and contrast changes will occur. Transport problems can also arise from inadequate replenishment; that is, if insufficient developer replenisher, the inadequate addition of hardener will result in excessive emulsion swelling. The essentially "thicker" film has difficulty transporting between the closely distanced rollers. As film travels through the fixer, it accumulates residual developer solution; fixer solution also accumulates unexposed silver cleared from the emulsion. The replenishment system assures that proper solution concentration is maintained. Because adjacent rollers are positioned closer together at their periphery, roller pressure on film emulsion is greater at film edges. This can cause a plus-density mottled appearance (wet-pressure sensitization marks) along film edges. If developer hardener or replenisher is insufficient, allowing excessive emulsion swelling, this artifact can occur across the length of the film. Developer is the most important solution temperature to regulate; in a 90-second processor, developer temperature is usually maintained at 92 F to 95 F. Once the correct developer temperature is established, it must be constantly maintained. Thus, the fixer temperature is regulated (in cold-water processors) by heat conducted from the developer solution. In older processors having stainless steel tanks, fixer temperature is regulated by heat convection from the neighboring developer solution. As temperature adjustments are made, the recirculation system agitates solution to promote temperature uniformity. Agitation provided by the system also functions to keep fresh solution in contact with film emulsion. The recirculation system also functions to filter debris, such as gelatin particles, from the solutions. Residual fixer will eventually stain the film a yellowish brown that ultimately obscures the image and diminishes the archival quality. Films can be tested (usually by the film manufacturer or distributor) to determine their degree of fixer retention. The dryer section functions to remove water from the film by blowing warm, dry air over the film surface. Dryer temperature is usually 120 F to 130 F, sufficient to shrink and dry the emulsion without being excessive. If films emerging from a properly heated dryer are damp, the problem may be excessive emulsion swelling and water retention as a result of inadequate developer or fixer replenisher (hardener). The other half (unexposed silver) is removed from the film during the fixing process, and most of it is recoverable through silver recovery methods. A drain is connected to the fixer tank, and fixer is allowed to flow directly into a silver recovery unit or to a large centrally located receptacle.
Glossopharyngeal neuralgia A rare disorder precipitated by swallowing arthritis in dogs and cats discount plaquenil 400mg with amex, which produces pain in the pharynx or deep inside the ear laser treatment for arthritis in dogs uk order plaquenil 400 mg with amex. Generalised seizures Generalised seizures are typified by widespread activity affecting both cerebral hemispheres and include arthritis diet for dummies purchase plaquenil 200 mg with amex. Postherpetic neuralgia Patients have a history of herpes zoster infection (shingles) in the distribution of one of the branches of the trigeminal nerve (usually ophthalmic) rheumatoid arthritis diet gluten free cheap plaquenil 200mg with mastercard. Pain, itching and altered sensation develop along the course of the affected nerve and persist after the rash has healed. The pain may be difficult to treat, but sometimes responds to tricyclic antidepressants, carbamazepine or topically applied capsaicin. There may be a family history suggesting genetic susceptibility, particularly with petit mal seizures. Seizures may be secondary to cerebral disorders, metabolic dysfunction and drug ingestion (Table 15. Atypical facial pain this describes episodic aching in the jaw and cheek (in a non-anatomical distribution), lasting several hours and usually occurring in young to middle-aged women who often exhibit coexistent features of anxiety or depression. Provocation of seizures A variety of factors can provoke seizures in patients not usually prone to epilepsy. In those with known epilepsy, seizures may be provoked by sleep deprivation, stress, alcohol and, occasionally, stimuli such as television or strobe lighting. Epilepsy Epilepsy results from intermittent paroxysmal electrical discharges of cerebral neurons causing stereotypical attacks of altered consciousness, motor or sensory function, behaviour or emotion. Ideally, all patients with a first unexplained seizure should be rapidly assessed by a neurologist in a specialist clinic. This is followed by loss of consciousness and the tonic phase (characterised by generalised muscle spasms), which usually lasts up to 30 s. The clonic phase, characterised by sharp repetitive muscular jerks in all limbs, follows. Consciousness remains impaired typically for around 30 min, with drowsiness and confusion lasting several hours. Temporal lobe epilepsy Patients typically experience an aura which may include a sense of fear or deja-vu, hallucinations (visual, olfactory or gustatory) or a rising sensation in the epigastrium. Confusion and anxiety may develop and some patients exhibit automatism (organised stereotyped movements. Jacksonian (focal) epilepsy Epileptic activity originates in one part of the motor cortex. Each seizure begins in one body part and may proceed to involve that side of the body and then the whole body. Febrile convulsions these are seizures occurring in the context of fever, usually in young children under 5. They are usually generalised and brief but occasionally longer lasting or focal in nature. Aetiology includes perinatal asphyxia, metabolic disorders, encephalitis and cerebral malformations. Juvenile myoclonic epilepsy this form of primary generalised epilepsy with typical onset in teenagers is characterised by relatively 176 Neurology Investigation the object is to detect treatable underlying brain disease and identify provoking factors. A full history and clinical examination should identify other causes of loss of consciousness. Biochemical evidence of excess alcohol, hypoglycaemia, hyponatraemia or hypocalcaemia should be sought. Status epilepticus this is defined as recurring or continuous seizures, in which the patient does not regain consciousness between attacks. It is a medical emergency as hypoxia/ anoxia can lead to permanent brain damage or even death. The choice of agent used to terminate seizure activity depends on the stage/duration, but may include. Management A single fit rarely requires treatment but an underlying cause should be sought. Most neurologists would begin treatment with prophylactic anticonvulsants after a second episode. However, it may be prudent to treat after a first seizure when neuroimaging reveals a structural lesion or when there is no reversible precipitant. The choice of pharmacological therapy is determined by the type of epilepsy, for example. Partial seizures (with or without secondary generalisation): carbamazepine, lamotrigine, oxcarbazepine and sodium valproate are the drugs of choice; second-line agents include clobazam, gabapentin, levetiracetam, pregabalin and topiramate. Absence: ethosuximide or sodium valproate are the drugs of choice for classical absence seizures; clonazepam and lamotrigine are alternatives. Myoclonic: sodium valproate is the drug of choice for most cases; clonazepam, levetiracetam and topiramate may be tried as second-line agents. Regular anticonvulsant therapy should be reinstituted as soon as possible in those with known epilepsy. Epilepsy and pregnancy Uncontrolled seizures in pregnancy present a serious risk to both mother and fetus. Anticonvulsant drugs must be continued especially if there is a history of recent seizure activity. Women with epilepsy who wish to become pregnant should receive pre-pregnancy counselling about the risk of congenital abnormality and the individual In addition, age, sex, child-bearing potential, comorbidity and concomitant medication should be taken into account. Seizure control with minimal adverse effects can be achieved using a single anticonvulsant in $75% of patients. The addition of a second drug produces satisfactory control in a further subgroup. Refractory epilepsy (inadequate control on multiple agents) may reflect: Neurology 177 pros and cons of continuing treatment. Screening for neural tube defects is especially indicated in women taking sodium valproate or carbamazepine, and folic acid supplementation is essential both preconception and throughout the pregnancy. For mothers taking carbamazepine, phenobarbitone or phenytoin (enzyme inducing agents), vitamin K should be prescribed before delivery and for the newborn. Stroke Stroke is characterised by rapidly developing symptoms and/or signs of loss of central nervous system function. It is distinguishable from a transient ischaemic attack (see below) by virtue of symptoms persisting for more than 24 h. Patients with a history of epilepsy must be seizure free for 1 year before being allowed to drive. More stringent regulations apply to licences for heavy goods or passengercarrying vehicles ( Patients with sleep-related epilepsy may drive if they have an established pattern of seizures that have occurred only in relation to sleep during the previous 3 years. Aetiology and pathophysiology Approximately 85% of cases are ischaemic (thrombosis or embolism) in origin, 10% are caused by intracerebral haemorrhage and 5% by subarachnoid haemorrhage. Epilepsy and employment There are certain statutory employment restrictions for individuals with epilepsy, including in relation to the emergency and armed services, pilots and train drivers. Prognosis in epilepsy the long-term prognosis of epilepsy is good, with most patients attaining a 5-year remission and many stopping treatment in due course. The decision to discontinue anticonvulsant therapy is determined by: Degenerative arterial disease is the most common cause of stroke. Risk factors include family history of premature vascular disease, smoking, hypertension, hyperlipidaemia, diabetes mellitus, excess alcohol ingestion and certain oral contraceptive preparations.
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