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By: Brindusa Truta, M.A.S., M.D.

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No miosis occurs on topical application of morphine to definition du cholesterol ldl purchase lipitor 10mg visa the eye cholesterol lowering diet chart purchase cheap lipitor line, since this is a central action cholesterol and lecithin in eggs cheap lipitor 5mg with amex. Muscular rigidity and immobility is consistently manifested at high doses (especially on i cholesterol levels measurement order lipitor 5 mg fast delivery. Species like cat, lion, horse, sheep and cow are uniformly excited and show hyperthermia. Some degree of tolerance may develop to this effect, but heavy abusers often suffer loss of libido, impotence, menstrual irregularities and infertility. There is a shift of blood from pulmonary to systemic circuit due to greater vasodilatation in the latter. Postural hypotension and fainting do occur due to venodilatation and impairment of vascular reflexes. Cardiac work is consistently reduced due to decrease in peripheral resistance, imparting anti-ischaemic property to morphine. Other smooth muscles (a) Biliary tract Morphine causes spasm of sphincter of Oddi intrabiliary pressure is increased several fold may cause biliary colic. This action is only partly counteracted by atropine but more completely by opioid antagonist naloxone and direct smooth muscle relaxants like nitrates. This is of no consequence in normal individuals, but can be dangerous in asthmatics. Distribution is wide; concentration in liver, spleen and kidney is higher than that in plasma. Morphine-6-glucuronide is an active metabolite (more potent than morphine on opioid receptors), which accumulates during chronic dosing and contributes to analgesia, despite its restricted passage across blood-brain barrier. Side effects Sedation, mental clouding, lethargy and other subjective effects which may even be dysphoric in some subjects; vomiting is occasional in recumbent patient; constipation is common and distressing. Respiratory depression, blurring of vision, urinary retention (especially in elderly male) are other side effects. Idiosyncrasy and allergy Allergic reactions manifesting as urticaria, swelling of lips occur infrequently. A local reaction at injection site and generalized itching may occur due to histamine release. Apnoea of the newborn this may occur when morphine is given to the mother during labour. The blood-brain barrier of the foetus is undeveloped, morphine attains higher concentration in foetal brain than in that of mother. Being a basic drug it is partitioned to the acid gastric juice, ionizes there and does not diffuse back into blood. Tolerance and dependence High degree of tolerance can be developed to morphine and related opioids if the drug is used repeatedly. It is partly pharmacokinetic (enhanced rate of metabolism), but mainly pharmacodynamic (cellular tolerance). Tolerance is exhibited to most actions, but not to constipating and miotic actions. Morphine produces pronounced psychological and physical dependence, its abuse liability is rated high. Thus, the analgesic action of morphine can be dissociated from tolerance and dependence which contribute to its abuse. Concern about abuse has been a major limitation in the use of morphine, but appropriate medical use of morphine seldom progresses to dependence and abuse. Morphine abuse is higher among medical and paramedical personnel because they have easier access to the drug. Earlier, morphine addicts tended to be from the middle age group, but now younger individuals are also opting for it. Delirium and convulsions are not a characteristic feature (contrast barbiturates) and are seen only occasionally. Cardiovascular collapse and fatality are rare if supportive measures are instituted. Opioid antagonists (naloxone, nalorphine) precipitate acute withdrawal syndrome in the dependent subject. Treatment: consists of withdrawal of morphine and substitution with oral methadone (long-acting, orally effective) followed by gradual withdrawal of methadone. Longterm methadone maintenance and other techniques using agonist-antagonistic drugs are also employed. Infants and the elderly are more susceptible to the respiratory depressant action of morphine. It is dangerous in patients with respiratory insufficiency (emphysema, pulmonary fibrosis, cor pulmonale); sudden deaths have occurred. Bronchial asthma: Morphine can precipitate an attack by its histamine releasing action.

This study is used to cholesterol test diy cheap 40 mg lipitor overnight delivery identify the upper collecting system in an obstructed kidney to good bad cholesterol foods list purchase lipitor cheap be used as a map for accurate percutaneous placement of a nephrostomy tube cholesterol esterase buy lipitor overnight delivery. This is performed on patients who have an obstruction of the ureter and hydronephrosis cholesterol medication zoloft lipitor 40mg with visa. Radiopaque dye P 780 pyelography is then injected and the entire upper renal collecting system is demonstrated by obtaining x-ray images in rapid succession. The patient is taken to the radiology department and placed in the supine position. X-ray images are taken at specific times, usually at 1, 5, 10, 15, 20, and 30 minutes and sometimes longer, to follow P 782 pyelography the course of the dye from the cortex of the kidney to the bladder. Inform the patient that the dye injection often causes a transitory flushing of the face, a feeling of warmth, a salty taste in the mouth, or even transient nausea. As the catheters are withdrawn, more dye is injected, and more x-ray images are taken to visualize the complete outline of the ureters. A delayed image is often performed to assess the emptying capabilities of the ureter. If obstruction is noted, a stent may be left in the ureter so that the ureter can drain. Under local anesthesia, a thin-walled needle is advanced into the lumen of the renal pelvis. The nephrostomy tube is placed over guidewires and its position is affirmed by repeating the x-rays. Abnormal findings Pyelonephritis Glomerulonephritis Kidney tumor Renal hematoma Renal laceration Cyst or polycystic disease of the kidney Congenital abnormality of the urologic tract Renal or ureteral calculi Trauma to the kidneys, ureters, or bladder Tumor of the collecting system Hydronephrosis Extrinsic compression of the collecting system. The rabies virus antibody test is also used in making the diagnosis of rabies in a patient suspected of having been exposed to the virus. When the value is decreased below the range of the expected normal value, the patient is said to be anemic. Hemoglobin content is indicated by the terms normochromic, hypochromic, and hyperchromic. During this procedure, a needle is inserted through the skin and into the kidney to obtain a sample of kidney tissue. This involves an incision through the flank and dissection to expose the kidney surgically. A biopsy needle is placed through the posterior lower chest wall and into the renal parenchyma, from which tissue is extracted. The patient is placed in a prone position with a sandbag or pillow under the abdomen to straighten the spine. Under sterile conditions, the skin overlying the kidneys is infiltrated with a local anesthetic (lidocaine). While the patient holds his or her breath to stop kidney motion, the physician inserts the biopsy needle into the kidney and takes a specimen. After this procedure is completed, the needle is removed, and pressure is applied to the site for approximately 20 minutes. Tell the patient that this procedure is uncomfortable but only minimally if enough lidocaine is used. Instruct the patient to avoid any activity that increases abdominal venous pressure. Instruct the patient to report burning during urination or development of a fever. Urine samples may be placed in consecutive chronologic order to facilitate comparison for evaluation of hematuria. Encourage the patient to drink large amounts of fluid to prevent clot formation and urine retention. They are also used to indicate the presence of ureteral obstruction or renovascular hypertension. Because this study uses no iodinated dyes, it is safe to perform on patients who have iodine allergies or compromised renal function. Renal scans are used to monitor renal function in patients with known renal disease. The radioactive material is detected by a scintillator camera, which can detect the gamma rays emitted by the radionuclide in the kidney. The resultant image (scan) indicates distribution of the radionuclide within the kidney and ureters. There are several kinds of renal scans, depending on what information is needed to be obtained. Different isotopes may be more suitable for different scans, based on the manner in which the kidney handles the radioisotope.

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Diagnosis Pts should undergo anoscopy to cholesterol levels stroke generic lipitor 5 mg without a prescription examine the rectal mucosa and exudates and to cholesterol in eyes lipitor 5 mg fast delivery obtain specimens for diagnosis cholesterol levels garlic discount lipitor 40mg line. Epidemiology the ~299 cholesterol test wrong purchase lipitor 10mg mastercard,000 cases reported in the United States in 2008 probably represent only half the true number of cases because of underreporting, selftreatment, and nonspecific treatment without a laboratory diagnosis. Penicillin, ampicillin, and tetracycline are no longer reliable therapeutic agents, and fluoroquinolones are no longer routinely recommended. Clinical Manifestations Except in disseminated disease, the sites of infection typically reflect areas involved in sexual contact. Pharyngeal infection almost always coexists with genital infection, resolves spontaneously, and is rarely transmitted to sexual contacts. Pts present during a bacteremic phase (relatively uncommon) or with suppurative arthritis involving one or two joints (most commonly the knees, wrists, ankles, and elbows), with tenosynovitis and skin lesions. Treatment for chlamydial infection (as above) should be given if this infection has not been ruled out. Fluoroquinolones may be an option if antimicrobial susceptibility can be documented by culture of the causative organism. Progressive periadenitis results in fluctuant, suppurative nodes with development of multiple draining fistulas. After a latent period, one-third of untreated pts eventually develop tertiary disease (syphilitic gummas, cardiovascular disease, neurologic disease). Clinical Manifestations Syphilis progresses through three phases with distinct clinical presentations. Meningeal syphilis presents as headache, nausea, vomiting, neck stiffness, cranial nerve involvement, seizures, and changes in mental status within 1 year of infection. Meningovascular syphilis presents up to 10 years after infection as a subacute encephalitic prodrome followed by a gradually progressive vascular syndrome. Tabes dorsalis is a demyelination of posterior columns, dorsal roots, and dorsal root ganglia, with ataxic, wide-based gait and footslap; paresthesia; bladder disturbances; impotence; areflexia; and loss of position, deep pain, and temperature sensations. Common sites include the skin and skeletal system; however, any organ (including the brain) may be involved. Diagnosis Serologic tests-both nontreponemal and treponemal-are the mainstays of diagnosis; changes in antibody titers can also be used to monitor response to therapy. After therapy for early syphilis, a persistent fall in titer by 4-fold is considered an adequate response. Azithromycin should not be used for men who have sex with men or for pregnant women. Source: Based on the 2010 Sexually Transmitted Diseases Treatment Guidelines from the Centers for Disease Control and Prevention. Daily valacyclovir appears to be more effective at reducing subclinical shedding than daily famciclovir. The infection is endemic in Papua New Guinea, parts of southern Africa, India, French Guyana, Brazil, and aboriginal communities in Australia; few cases are reported in the U. Four types of lesions have been described: (1) the classic ulcerogranulomatous lesion that bleeds readily when touched; (2) a hypertrophic or verrucous ulcer with a raised irregular edge; (3) a necrotic, offensive-smelling ulcer causing tissue destruction; and (4) a sclerotic or cicatricial lesion with fibrous and scar tissue. Pts should be treated with azithromycin (1 g on day 1, then 500 mg qd for 7 days or 1 g weekly for 4 weeks); alternative therapy consists of a 14-day course of doxycycline (100 mg bid), trimethoprim-sulfamethoxazole (960 mg bid), erythromycin (500 mg qid), or tetracycline (500 mg qid). If any of the 14-day treatment regimens are chosen, the pts should be monitored until lesions have healed completely. Diagnosis Most visible warts are diagnosed correctly by history and physical examination alone. Treatment of common skin infections is summarized in Table 93-1; parenteral treatment is usually given until systemic signs and symptoms have improved.

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Identify patients on anticoagulants since they are higher risk for spinal epidural hematoma or retroperitoneal hemorrhage which can present as back pain 6 cholesterol xrd cheap 5 mg lipitor free shipping. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities 6 cholesterol levels for 50 year old male cheap lipitor 5 mg online. Exclusion Criteria Complaints unrelated to definition of cholesterol in science lipitor 10mg lowest price the illness for which the patient is receiving those services cholesterol ratio average buy lipitor 40mg amex. If the patient is able to communicate and has the capacity to make decisions regarding treatment and transport, consult directly with the patient before treatment and/or transport 3. If the patient lacks the capacity to make decisions regarding treatment and/or transport, identify any advanced care planning in place for information relating to advanced care planning and consent for treatment a. In collaboration with hospice or palliative care provider, coordinate with guardian, power of attorney, or other accepted healthcare proxy if non-transport is considered Patient Safety Considerations 1. Careful and thorough assessments should be performed to identify complaints not related to the illness for which the patient is receiving hospice or palliative care 2. Care should be delivered with the utmost patience and compassion Notes/Educational Pearls Key Considerations 1. Scene safety should be considered when deciding on management Pertinent Assessment Findings 1. Appropriate hydration for hyperglycemia Patient Presentation Inclusion Criteria 1. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline] 2. Adult or pediatric patient with history of diabetes and other medical symptoms Exclusion Criteria Patient in cardiac arrest. Evaluate for possible concomitant sepsis and septic shock [see Shock guideline] 4. If altered level of consciousness, stroke, or sepsis/septic shock, treat per Altered Mental Status, Suspected Stroke/Transient Ischemic Attack, or Shock guidelines accordingly 2. If glucose greater than 250 mg/dL with symptoms of dehydration, vomiting, abdominal pain, or altered level of consciousness: a. If mental status changes, reassess blood glucose level and provide appropriate treatment if hypoglycemia has developed 6. Transport to closest appropriate receiving facility Patient Safety Considerations 1. Overly aggressive administration of fluid in hyperglycemic patients may cause cerebral edema or dangerous hyponatremia a. Asymptomatic hyperglycemia poses no risk to the patient while inappropriately aggressive interventions to manage blood sugar can harm patients Notes/Educational Pearls Key Considerations 1. New onset diabetic ketoacidosis in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency 2. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Outcome of diabetic patients treated in the prehospital arena after a hypoglycemic episode, and an exploration of treat and release protocols: a review of the literature. Revision date September 8, 2017 77 Hypoglycemia Aliases Diabetic coma, insulin shock Patient Care Goals 1. Adult or pediatric patient with blood glucose less than 60 mg/dL with symptoms of hypoglycemia 2. Adult or pediatric patient with altered level of consciousness [see Altered Mental Status guideline] 3. Adult patient who appears to be intoxicated Exclusion Criteria Patient in cardiac arrest Patient Management Assessment 1. Evaluate for presence of an automated external insulin delivery device (insulin pump) b. Assess for focal neurologic deficit: motor and sensory Treatment and Interventions 1. If altered level of consciousness or stroke, treat per Altered Mental Status or Suspected Stroke/Transient Ischemic Attack guidelines accordingly 2. Repeat check of blood glucose level if previous hypoglycemia and mental status has not returned to normal i. It is not necessary to repeat blood sugar if mental status has returned to normal c.

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On the third postpartum day a client tells the nurse that she feels sad and that she cries easily cholesterol lowering foods list mayo clinic buy 40mg lipitor mastercard. If the client focuses on the fact that she has a healthy baby cholesterol spinach generic lipitor 10 mg amex, the feelings will cease cholesterol levels recommended uk order lipitor 40mg without a prescription. When the client is home with her family and friends cholesterol ratio of 5 buy lipitor 40 mg without a prescription, her sad feelings will disappear. A nurse is reading a research study that states, "There is a strong negative correlation between the independent and dependent variables (r 0. As values of the independent variable go up, values of the dependent variable go down. When the confidence interval is computed, the negative value will change to positive. A doula is working with a laboring woman who is 6 cm dilated and is contracting every 3 min 60 sec on an oxytocin drip. The nurse should teach the woman to try which of the following self-care measures? It is noted that a baby admitted to the nursery has translucent skin with visible veins. Because of this finding, the nurse should monitor this baby carefully for which of the following? A 32-week-gravid client presents in the emergency department with severe abdominal pain, rigid abdomen, and scant dark red bleeding. A woman, who is in pain from a diagnosis of mastitis, has abruptly weaned her baby to a bottle. The triage nurse is interviewing a client, 19 years old, unmarried, who states, "I felt a hard thing on the lip of my vagina this morning. The nurse is providing anticipatory guidance about what signs to expect the baby to exhibit every 24 hours by the end of the first week. Please indicate the frequency and duration of the contraction pattern shown below. In the teaching session, which of the following should the nurse tell the woman to do? Which of the following complications that occurred immediately after delivery could have resulted in this condition? During a vaginal delivery of a macrosomic baby, the nurse midwife requests nursing assistance. A postpartum client, who delivered her baby vaginally 2 hours earlier, just voided 100 cc in the bathroom. After returning to bed, the nurse makes the following assessment: fundus 4 cm above the umbilicus and deviated to the right with moderate lochia rubra. A nurse should monitor a client who is postpartum from a forceps delivery for which of the following complications? A fetal fibronectin assessment on the cervicovaginal fluids of a 28-week gravida is positive. Based on the results, which of the following complaints should the nurse advise the client to report immediately to the health care provider? A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched? A fetus, descending through the birth canal, is going through the cardinal moves of labor. When caring for a woman a nurse suspects is being abused by her partner, the nurse should do which of the following? The nurse is obtaining the first postpartum meal for a client who has stated that she practices Mormonism (The Church of Jesus Christ of Latter-Day Saints). Based on this decision, which of the following instructions should the nurse include in the parent teaching? The couple should fully retract the foreskin to assess for the presence of exudate every morning. The pediatrician will observe the baby void during each well baby examination to assess for a phimosis. Which of the following fetal heart changes would the nurse expect to observe on the internal fetal monitor tracing? Which of the following features would the nurse expect to be absent in an 8-weekgestation embryo? On vaginal exam, the cervix is 4 cm dilated and 80% effaced, and the station is 2.

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References:

  • https://docs.boehringer-ingelheim.com/Prescribing%20Information/PIs/Glyxambi/Glyxambi.pdf
  • https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/CT092060277_01.pdf
  • http://jefferson.floridahealth.gov/_files/_documents/Moderna-Vaccine-Screening-and-Consent-Form.pdf
  • https://bioness.com/Documents/H200HCP/Mp602-00503-001_RevE[e-file].pdf
  • https://www.venousdisease.com/caprini-dvt-risk-assessment.pdf

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