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Insight (patient s replies to questions about the chief symptoms): What is your dif culty Are you ill When did your illness begin Orientation (knowledge of personal identity and present situation): What is your name, address, telephone number What is your occupation Are you married a Place: What is the name of the place where you are now (building, city, state) How did you get here What oor is it on Where is the bathroom b Time: What is the date today (day of week and of month, month, year) What time of the day is it What meals have you had When was the last holiday Memory a Remote: Tell me the names of your children (or grandchildren) and their birth dates.

When were you married What was your mother s maiden name What was the name of your rst schoolteacher What jobs have you held We also nd it useful to quiz the patient about cultural icons of the past that are appropriate to his age Most patients should be able to name the presidents in reverse order dating to their twenties b Recent past: Tell me about your recent illness (compare with previous statements) What is my name (or the nurse s name) When did you see me for the rst time What tests were done yesterday What were the headlines of the newspaper today c Immediate recall (attention and short-term memory ): Repeat these numbers after me (give series of 3, 4, 5, 6, 7, 8 digits at a speed of one per second) Now when I give a series of numbers, repeat them in reverse order d.

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Memorization (learning): The patient is given three or four simple data (examiner s name, date, time of day, and a fruit, structure, or trait, such as honesty we use a red ball, Beacon Street, and an envelope ) and is asked to repeat them after a minute or a brief story containing several facts and is asked to recount the main.

AND PROTEIN DEGRADATION. There are two ways to maintain blood glucose levels degradation of glycogen and synthesis of glucose from pyruvate (gluconeogenesis). Glycogen is stored in the liver and muscle. Gluconeogenesis is the major domain of the liver and kidney. When the glucose level is low, liver and kidney supply glucose to the blood to maintain the supply by stimulating the degradation of glycogen and by stimulating the synthesis of glucose through gluconeogenesis.

This drug is used in the treatment of acute lymphoblastic leukemia, lymphomas, and some solid tumors. Its most important toxic side effect, and the one that limits its use as a chemotherapeutic agent, is a peripheral neuropathy. Paresthesias of the feet, hands, or both may occur within a few weeks of the beginning of treatment; with continued use of the drug, a progressive symmetrical neuropathy evolves (mainly sensory with re ex loss). Cranial nerves are affected less frequently but ptosis and lateral rectus, facial, and vocal cord palsies have been observed. Autonomic nervous system function may also be affected: constipation and impotence are frequent complications; orthostatic hypotension, atonicity of the bladder, and adynamic ileus are less frequent. The polyneuropathy due to vincristine is described more fully on page 1133. Inappropriate antidiuretic hormone secretion and seizures have been reported but are uncommon. Although rarely noted in the literature, the authors have seen an instance of reversible posterior leukoencephalopathy with cortical blindness and headache after a single dose of vincristine, identical to the syndrome reported with the use of cyclosporine and FK506 (Fig. 43-1). This radiologic appearance is also well known in hypertensive encephalopathy as discussed in Chap. 34. The main drugs implicated in this disorder are listed in Table 43-1. It has not been satisfactorily established if all such cases are the result of acute hypertension caused by the implicated drug or if there might be an additional direct toxic effect on the white matter. The neural complications of vinblastine are similar to those of vincristine but are usually avoided because bone marrow suppression limits the dose of the drug that can safely be employed. Vinorelbine is a more recently introduced semisynthetic vinca alkaloid. It has much the same antitumor activity as vincristine but is supposedly less toxic.

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