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Types: - Useful productive cough o Effectively expels secretions and exudates - Useless cough o Non-productive chronic cough o Due to smoking and local irritants Anti-tussives are drugs used to suppress the intensity and frequency of coughing order 4 mg detrol with mastercard. Central anti- tussives - Suppress the medullay cough center and may be divided into two groups: o Opoid antitussive e cheap detrol 4mg on line. Peripheral antitussives - Decrease the input of stimuli from the cough receptor in the respiratory passage generic 4mg detrol with visa. Ipecac alkaloid, sodium citrate, saline expectorant, guanfenesin, potassium salts Mucolytics are agents that liquefy mucus and facilitate expectoration, e. Mechanism of Action Mucus membrane decongestants are α1 agonists, which produce localized vasoconstriction on the small blood vessels of the nasal membrane. Clinical uses: Used in congestion associated with rhinitis, hay fever, allergic rhinitis and to a lesser extent common cold. Short acting decongestants administered topically – phenylepherne, phenylpropanolamine 2. Long acting decongestants administered orally - ephedrine, pseudoephedrine, naphazoline 3. Long acting topical decongestants o Xylometazoline o oxymetazoline 83 Side effects: 1. Tachycardia, arrhythmia, nervousness, restlessness, insomnia, blurred vision Contraindications 1. Drugs used in Acid-peptic disease: Acid-peptic disease includes peptic ulcer (gastric and duodenal), gastroesophageal reflux and Zollinger – Ellison syndrome. Peptic – ulcer disease is thought to result from an imbalance between cell – destructive effects of hydrochloric acid and pepsin and cell-protective effects of mucus and bicarbonate on the other side. Pepsin is a proteolyic enzyme activated in gastric acid, also can digest the stomach wall. A bacterium, Helicobacter pylori is now accepted to be involved in the pathogenesis of ulcer. In gastroesophageal reflux, acidic stomach contents enter into the esophagus causing a burning sensation in the region of the heart; hence the common name heartburn, or other names such as indigestion, dyspepsia, pyrosis, etc. They are used as gastric antacids; and include aluminium, magnesium and calcium compounds e. Calcium compounds are effective and have a rapid onset of action but may cause hypersecretion of acid (acid - rebound) and milk-alkali syndrome (hence rarely used in peptic ulcer disease). All gastric antacids act chemically although some like magnesium trisiolicate can also act physically. Antacids act primarily in the stomach and are used to prevent and treat peptic ulcer. Antisecretory drugs include: • H 2-receptors blocking agents such as cimetidine, ranitidine, famotidine, nizatidine. Common adverse effects: muscular pain, headache, dizziness, anti- androgenic effects at high doses such as impotence,gynecomastia,menstrual irregularities. Drug interactions may occur when it is co-adminstered with warfarin, theophylline, phenytoin, etc. Anticholinergic agents such as pirenzepine, dicyclomine Major clinical indication is prevention & treatment of peptic ulcer disease, Zollinger Ellison syndrome, reflux esophagitis. However, they are combined with H2-antagonists to further decrease acid secretion, with antacids to delay gastric empting and thereby prolong acid – neutralizing effects, or with any anti-ulcer drug for antispasmodic effect in abdominal pain. Locally active agents help to heal gastric and duodenal ulcers by forming a protective barrier between the ulcers and gastric acid, pepsin, and bile salts. Laxatives and cathartics (purgatives) Laxatives and cathartics are drugs used orally to evacuate the bowels or to promote bowel elimination (defecation). The term cathartic implies strong effects and elimination of liquid or semi liquid stool. Both terms are used interchangeably because it is the dose that determines the effects rather than a particular drug. Example:- castor oil laxative effect= 4ml Cathartic effect = 15-60ml Laxative and cathartics are arbitrarily classified depending on mode of action as: • Bulk forming laxatives: are substances that are largely unabsorbed from the intestine. When water is added, the substances swell and become gel-like which increases the bulk of the fecal mass that stimulates peristalsis and defecation. Osmotic laxatives such as magnesium sulfate, magnesium hydroxide, sodium phosphate, etc. These substances are not efficiently absorbed, thus creating a stronger than usual solution in the colon which causes water to be retained. Individual drugs are castor oil, bisacodyl, phenolphthalein, cascara sagrada, glycerine, etc. It lubricates the intestine and is thought to soften stool by retarding colonic absorption of fecal water.

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Posterior chamber - Limited anteriorly and laterally by the posterior iris surface and ciliary body and posterior by lens & vitreous body C 4 mg detrol visa. Vitreous space - Filled with vitreous humor - Transparent order detrol 1mg without a prescription, roughly spherical and gelatinous structure occupying posterior 4/5 of the globe with volume of 4 ml detrol 2 mg on line. The lymphatic drainage of the medial eye lid is to sub mandibular lymph node and that of lateral one is to the superficial preauricular lymph nodes and then to deeper cervical lymph nodes. Ahmed 4 - Albert and Jakoboiec Principle and practice of ophthalmology 5 - Up to date - (C) 2001 - www. To give a clear idea about the approach to ophthalmic patients and specific examination techniques. At the end of the course the students are expected to know how to examine ophthalmic patients and use of certain ophthalmic instruments 2. Family history The main purpose of the history is to find out what exactly the patient is complaining. However it is always helpful to find out some background information about the patient e. Such information will indicate what vision the patient needs for work and for personal satisfaction. Major symptom of eye disease given • Disturbances of vision • Discomfort or pain in the eye • Eye discharge A. Disturbances of vision • The most common visual symptom • Can be sudden or gradual ¾ Blurring or reduction of vision ¾ Dazzling/glare/ – difficulty of seeing in bright light, may be caused by opacities in the cornea or lens ¾ Diplopia/ double vision/ ¾ Decreased peripheral vision – may be caused by various disorders in the retina, optic nerve or visual pathway pathology up to the visual cortex. Visual field Visual field is that portion of one’s surroundings that is visible at one time during central vision Not a routine test in all patients ¾ Important to do in any patients with suspected glaucoma, diseases of the optic nerves in visual pathways, and certain retinal diseases Confrontation test - Simple and no need of special equipment - Will detect serious visual field defects. To examine the front of the eye, this requires both a good light illumination with bright light, torch and magnifying lens(loupe). Normal eye • Eye lids should open and close properly • Eye lashes should grow forward and out ward • white part of the eye should be white • Cornea should be clear and transparent • Pupil is black and reactive to light During Examination of the Eye One Has to Comment the Following Things 1. Examination of the front aspect of the eye Eye lids – ™ In growing eye lash, misdirected ™ Everted eyelid examinations; follicles, papillary reaction, foreign body, concretions ™ Any mass, ulcer, discharge • Characterize it ™ Opening and closing pattern and defect of eye lid • Lagophthamos – eye lid that can’t close • Ptosis – eye lid drooping Nasolacrimal apparatus ™ Punctum ™ Mass, Ulcer or discharge over the Nasolacrimal apparatus Conjunctiva ƒ Color ƒ Growth 22 ƒ Bleeding ƒ Foreign body ƒ Spot - white foamy ƒ Follicles, papillae, scarring Characterize each findings Limbus ƒ Herbert’s pit ƒ Ciliary /circumcorneal/ injection ƒ Arcus Cornea Color and transparency Size Ulcer, scar, infiltrates Foreign body Laceration, perforation Blood vessels growth Sensation to touch Iris /pupil • Color ƒ Defect ƒ Reaction to light ƒ Relation with adjacent parts ƒ Pupillary margin: shape, adhesion between lens , iris and cornea Lens ƒ Transparency ƒ Position, sublaxated or dislocated 23 Anterior chamber • look for clarity • Depth 2. Ophthalmoscope is a form of illumination, which allows the examiner to look down the same axis as the rays of light entering the patient’s eye. To see the fundus • Ocular media must be healthy and transparent • Dilate the pupil with mydriatic drops • With the ophthalmoscope it appears 15 times larger than its actual size • In myopic patient the magnification is greater, but in hypermetropic patient it is less. Select ‘’ O’’ on the illuminated lens dial of the ophthalmoscope and start with small aperture. Take the ophthalmoscope in the right hand and hold it vertically in front of your own right eye with the light beam directed toward the patient and place your right index finger on the edge of the lens dial so that you will be able to change lenses easily if necessary. Position the ophthalmoscope about 6 inches (15cm) in front and slightly 0 to the right(25 ) of the patient and direct the light beam into the pupil. Rest the left hand on the patient’s forehead and hold the upper lid of the eye near the eyelashes with the thumb. While the patient holds his fixation on the specified object, keep the ‘’ reflex’’ in view and slowly move toward the patient. The optic disc should come into view when you are about 1and1/2 to 2 inches (3-5cm) from the patient. If it is not focused clearly, rotate lenses into the aperture with your index finger until the optic disc is clearly visible as possible. The hyperopic, or far- sighted, eye requires more‘’ plus’’(black numbers)sphere for clear focus; the myopic, or near-sighted, eye requires ‘’ minus’’(red numbers) sphere for clear focus. Now examine the disc for clarity of outline, color, elevating and condition of the vessels. To locate the macula, focus on the disc, then move the light approximately 2 disc diameters temporally. You may also have the patient look at the light of the ophthalmoscope, which will automatically place the macula in full view. The red-free filter facilitates viewing of the center of the macula, or the fovea. To examine the left eye, repeat the procedure outlined above except that you hold the ophthalmoscope in the left hand, stand at the patient’s left side and use your left eye. If the patient has a refractive error, try dialing up plus or minus lenses in the ophthalmoscope to bring the fundus into focus. It is difficult to see the fundus clearly so use a strong minus lens in the ophthalmoscope. Seat the baby on his mother’s lap, so that her hands restrain his arms and steady his head 2.

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If starting with 2 mg and patient uncontrolled at 20 minutes quality detrol 2mg, increase to 5 mg and follow guidelines above generic detrol 4 mg fast delivery. Once patient responds to haloperidol buy 2 mg detrol with mastercard, 25% of the loading dose required should be given every 6 hours on a scheduled basis. If patient is still not effectively sedated with maximum daily doses of haloperidol, consider using a different drug for sedation or the addition of a second drug with haloperidol (e. Extrapyramidal symptoms, parkinsonian symptoms, akathisias, dystonic reactions, and tardive dyskinesia (long-term use) b. To be used for complete or partial reversal of narcotics in suspected overdose or for diagnostic/therapeutic purposes. No clear benefit from treatment (Pollycarpou et al Anticonvulsants for alcohol withdrawal Cochrane Rev 2005). Alcoholic hallucinosis – Hallucinations that develop within 12-24 hours and resolve within 24-48 hours. Approximate 90% of individuals who drink etoh for >40+ consecutive days develop major withdrawal symptoms. In contrast, in individuals with sustained intake <30 days most develop only minor symptoms upon cessation of alcohol (Isbell et al Q J Stud Alcohol 1955). Controversy over use of anti-psychotics relates to the potential for these agents to lower seizure threshold. For all definitions below, pneumonia equals a new infiltrate, signs/symptoms of infection (fever, leukocytosis), purulent sputum, and/or worsening oxygenation. Anaerobes are rarely pathogens alone; only need to treat in chronic aspiration with pleuropulmonary involvement. Bacteriologic strategies using quantitative culture thresholds result in less antibiotic use; however suffer from methodologic difficulty (lab expertise, bronchoscopy). Severe Obructive Lung Disease : Asthma Acute severe asthma with impending respiratory failure Issue in Presentation and Severity 1. Acute Asphyxia Asthma Slowly progressive over days or weeks Rapid Onset Inflammation / Eos and Mucus Little inflammation / mucus- probably smooth muscle contraction Unlikely to improve rapidly – May rapidly improve with bronchodilators ++++ Initial Risk of high Barotrauma / autopeep +++++ +++ Atelectasis + Management: 1. Corticosteroids: Dose: Study: Solumedrol at 125 or 40mg better than 15mg Usual 60-125mg every 6-8 hrs overnight Type: No specifics c. Oxygenation: Usually not a major problem – if hypoxic likely to represent mucus plugging + lobar collapse. Hypoventilation reflects an inability to get sufficient air to the alveoli for gas exchange due to severe air-trapping. In addition there is complex V/Q mismatching with high airway pressures (peep) creating areas of lung without effective perfusion (essentially dead space). Synchrony: Tachypnea, air-trapping, and severe acidosis make it impossible for patient to synchronize – requires heavy sedation + paralysis d. Barotrauma: High air pressure generally reflects dynamic (airway resistance = peak – plateau pressure) but static (plateau pressure) is also increased due to air-trapping. If initial ventilation strategy results in significant stacking of breaths and thus autopeep or dynamic hyperinflation - eventually this will cause decreased venous return with hypotension, shock, cardiac arrest etc. The aim is to limit minute ventilation and maximize expiratory time, and thus reduce the risk of air- trapping. Daily Transcranial Doppler exams may detect impending spasm before clinical symptoms (stroke) develop. Other treatments of vasospasm include angiography w/angioplasty, and/or intra-arteial milrinone or papaverine (case reports). Refractory status epilepticus- continual seizures after 1-2 meds have been tried 20% of these patients go on to have persistent neurological defects- behavior, memory, emotional Incidence of status epilepticus- Less than 1 % of all seizures Management – 1. Hypertensive emergency- increase in systolic and diastolic blood pressure leading to end-organ damage A. The clinical differentiation between these two entities is the presence or absence of end organ damage not the level of blood pressure elevation. The aim is to lessen pulsatile load and force of left ventricular contraction to slow the propagation of the dissection. Definition: Hyponatremia is generally defined as a plasma sodium level of less than 135 mEq per L (135 mmol per L). Pseudohyponatremia: This condition results from increased percentage of large molecular particles in the serum relative to sodium. These large molecules do not contribute to plasma osmolality resulting in a state in which the relative sodium concentration is decreased, but the overall osmolality remains unchanged. Glucose molecules exert an osmotic force and draw water from the intracellular compartment into the plasma, thereby causing a diluting effect. Hypervolemic hyponatremic conditions: congestive heart failure, liver cirrhosis, and renal diseases such as nephrotic syndrome. Treatment: Step 1: Based on Na levels and severity of symptoms decide whether immediate treatment is required. In patients with chronic hyponatremia, overzealous and rapid correction should be avoided because it can lead to central pontine myelinolysis. In central pontine myelinolysis, neurologic symptoms usually occur one to six days after correction and are often irreversible.

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The low partial pressure of oxygen at high altitudes results in a lower oxygen saturation level of hemoglobin in the blood discount 1 mg detrol fast delivery. Even though there is low saturation of each hemoglobin molecule purchase 4mg detrol overnight delivery, there will be more hemoglobin present discount 2 mg detrol, and therefore more oxygen in the blood. Until birth, however, the mother provides all of the oxygen to the fetus as well as removes all of the fetal carbon dioxide via the placenta. By week 28, enough alveoli have matured that a baby born prematurely at this time can usually breathe on its own. The respiratory system, however, is not fully developed until early childhood, when a full complement of mature alveoli is present. Ectodermal tissue from the anterior head region invaginates posteriorly to form olfactory pits, which fuse with endodermal tissue of the developing pharynx. The laryngotracheal bud is a structure that forms from the longitudinal extension of the lung bud as development progresses. The portion of this structure nearest the pharynx becomes the trachea, whereas the distal end becomes more bulbous, forming bronchial buds. A bronchial bud is one of a pair of structures that will eventually become the bronchi and all other lower respiratory structures (Figure 22. Weeks 16–24 Once the respiratory bronchioles form, further development includes extensive vascularization, or the development of the blood vessels, as well as the formation of alveolar ducts and alveolar precursors. Surfactant levels are not generally adequate to create effective lung compliance until about the eighth month of pregnancy. The respiratory system continues to expand, and the surfaces that will form the respiratory membrane develop further. At this point, pulmonary capillaries have formed and continue to expand, creating a large surface area for gas exchange. The major milestone of respiratory development occurs at around week 28, when sufficient alveolar precursors have matured so that a baby born prematurely at this time can usually breathe on its own. Fetal “Breathing” Although the function of fetal breathing movements is not entirely clear, they can be observed starting at 20–21 weeks of development. Fetal breathing movements involve muscle contractions that cause the inhalation of amniotic fluid and exhalation of the same fluid, with pulmonary surfactant and mucus. Fetal breathing movements are not continuous and may include periods of frequent movements and periods of no movements. For example, high blood glucose levels, called hyperglycemia, can boost the number of breathing movements. Conversely, low blood glucose levels, called hypoglycemia, can reduce the number of fetal breathing movements. Fetal breathing may help tone the muscles in preparation for breathing movements once the fetus is born. As the fetus is squeezed through the birth canal, the fetal thoracic cavity is compressed, expelling much of this fluid. The first inhalation occurs within 10 seconds after birth and not only serves as the first inspiration, but also acts to inflate the lungs. Pulmonary surfactant is critical for inflation to occur, as it reduces the surface tension of the alveoli. Preterm birth around 26 weeks frequently results in severe respiratory distress, although with current medical advancements, some babies may survive. Prior to 26 weeks, sufficient pulmonary surfactant is not produced, and the surfaces for gas exchange have not formed adequately; therefore, survival is low. A small amount of pulmonary surfactant is produced beginning at around 20 weeks; however, this is not sufficient for inflation of the lungs. At the time of delivery, treatment may include resuscitation and intubation if the infant does not breathe on his or her own. These infants would need to be placed on a ventilator to mechanically assist with the breathing process. Supportive therapies, such as temperature regulation, nutritional support, and antibiotics, may be administered to the premature infant as well. From a functional perspective, the respiratory system can be divided into two major areas: the conducting zone and the respiratory zone. The conducting zone consists of all of the structures that provide passageways for air to travel into and out of the lungs: the nasal cavity, pharynx, trachea, bronchi, and most bronchioles. The nasal passages contain the conchae and meatuses that expand the surface area of the cavity, which helps to warm and humidify incoming air, while removing debris and pathogens. The pharynx is composed of three major sections: the nasopharynx, which is continuous with the nasal cavity; the oropharynx, which borders the nasopharynx and the oral cavity; and the laryngopharynx, which borders the oropharynx, trachea, and esophagus. The respiratory zone includes the structures of the lung that are directly involved in gas exchange: the terminal bronchioles and alveoli. The lining of the conducting zone is composed mostly of pseudostratified ciliated columnar epithelium with goblet cells. The mucus traps pathogens and debris, whereas beating cilia move the mucus superiorly toward the throat, where it is swallowed. As the bronchioles become smaller and smaller, and nearer the alveoli, the epithelium thins and is simple squamous epithelium in the alveoli.