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By: Rasheed Adebayo Gbadegesin, MBBS

  • Professor of Pediatrics
  • Professor in Medicine
  • Affiliate of Duke Molecular Physiology Institute

https://medicine.duke.edu/faculty/rasheed-adebayo-gbadegesin-mbbs

Direct trainees to gastritis y embarazo order zantac online from canada practice identifying the class and category of the medications they assist Residents with during the next several days gastritis que puedo comer buy discount zantac 150 mg online. Many medications in use today are derived from higher plants and many imitate actual plant constituents gastritis jaw pain purchase 300 mg zantac free shipping. The following Web sites and herbal products are not inclusive gastritis diet purchase 150 mg zantac visa, either in content or in usage gastritis diet purchase zantac 300mg line, and are only intended as informational gastritis diet pregnancy purchase 150 mg zantac with amex. Johns Wort anti-depressive and psychotropic activity; wound healing; antiviral Valerian anxiety; insomnia; carminative Note: Many of the agents listed above are associated with adverse reactions and/or drug-herb interactions when combined with prescription and/or non-prescription medications. Consult your pharmacist provider and/or pharmacist consultant when using such agents. Cephalosporins (Ceclor, Cedax, Cefdinir, Cefzil, cephalexin, Rocephin, Lorabid, Vantin, Velosef) c. Vasodilators (isosorbide, minoxidil, nitroglycerin [tablets, capsules, patch, ointment] b. Beta Blockers (atenolol, Inderal, Lopressor, metoprolol, propranolol, Tenormin) d. Diuretics (Aldactone, Bumex, Demedex, furosemide, Lasix, spironolactone, thiazides) g. Beta2-agonist Inhalers (albuterol, Alupent, Brethaire, Foradil, Maxair, Proventil, Serevent, Ventolin) k. Other examples: Duty Area 3 Trainee Handout 45 5. Other (Celontin, Depakene, valproic acid Depakote, Felbatol, Gabitril, Keppra, Lamictal, Milontin, Neurontin, Topamax, Zarontin, Zonegran) f. Amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, protriptyline b. Other examples: Duty Area 3 Trainee Handout 46 11. Other examples: Duty Area 3 Trainee Handout 47 18. Other examples: Duty Area 3 Trainee Handout 48 24. Can be purchased by the consumer without a prescription and the sealed package provided to the facility. May interact with prescription drugs or foods For reference see, Advice for the Patient: Drug Information in Lay Language, Vol. Use your facilitys drug reference materials to look up medications you have seen used frequently for your residents. Additional reference materials are available from the pharmacist, pharmaceutical manufacturers and through the Internet. Discuss any questions you have about the drugs that you read about with the registered nurse. Duty Area 3 Trainee Handout 50 Identifying Classes of Medications Multiple Choice: Circle letter of the correct answer. Which of the following statements accurately describes a medication on the controlled substance list Performance Objectives: Given information, discussion, and practice activities, identify medication purpose, effects and interactions by orally describing the general purpose and effects of medication and answering at least two questions regarding the unwanted effects/interactions of medication. Enabling Objectives: Describe the importance of knowing the purpose and effects of medications and using available resources for obtaining desired information. Importance of understanding purpose and effects available material related to this task of medications. Purpose of medication achieving desired effects Explain that the purpose of medication (beneficial effects of medication). Definition of drug-drug interaction (Unwanted use by the personal care assistants. Increase the effects of one or more of the be copied are included in this medications. Greater number of medications taken, practice facilitating resident awareness greater chance for interaction. Examples of unwanted effects: explaining desired effects, unwanted effects including drug interactions, and 1. Rashes no apparent effects to a partner or, with supervision, to an actual resident. Blurred vision Have each trainee demonstrate his or her knowledge of purpose and effects of 7. Lethargy included in the instructor materials section of this unit for use with a F. Increased effects of the infection, due to the co-administration of antacids containing magnesium, aluminum or calcium is likely to be the result of a drug interaction. Recognizing Purpose and Effects of Medications Case and Questions: the following case and questions may be used by the instructor to evaluate trainees on their ability to discuss the general purpose and effects of medication and to answer question about unwanted effects. Bill Baggins is a resident at the Assisted Living facility where you work as a Certified Medication Aide. He is a responsible person capable of making decisions about his medication and capable of self-administering medication. He is reluctant to take the medication because he is not sure what the medication is for, and he is worried about unwanted effects. Tell him which licensed health care professional(s) can provide him with specific information about unwanted effects of doxycycline If Mr. Baggins infection is not affected by the doxycycline after 10 days, is this an unwanted effect or no apparent effect However, he reports extreme nausea and abdominal pain after taking an anti-inflammatory medication (ibuprofen) with his regular dose of doxycycline. Duty Area 4 Evaluation 56 Facilitating Resident Awareness of the Purpose and Effects of Medication Effects of Medication: the human body does not always function perfectly. No apparent effect Desired Effects: Medications are given or prescribed for many reasons. Some examples include: nutritional supplements to promote health insulin to control a disease cough suppressants and acetaminophen to reduce symptoms of an illness antibiotics such as amoxicillin to eliminate an illness anti-depressants, anti-anxiety agents, anti-psychotics to affect mind, mood or mental status When the prescribed drug is working correctly, we say the medication is producing the desired effect. Unwanted Effects: When a medication is taken, there is always the possibility that the resident may not have the response to the drug that was expected to occur. Some of the outcomes can be life threatening such as a serious reaction to penicillin or penicillin-related antibiotics. Drowsiness may not occur in every person for whom the drug was prescribed, but happens frequently. Duty Area 4 Trainee Handout 57 Unwanted effects may be unexpected and unpredictable. Some people are very allergic to a drug such as penicillin and have a reaction that could be fatal. In addition, people may have a reaction to a drug that is chemically similar to another product. Drug Interactions: When a person is taking two or more drugs at one time, the drugs may interact with each other. Looking for Unwanted Effects of Drugs: Unwanted effects show up in either physical or behavioral change. Any change occurring in the first few days of a new drug is important because it may have been caused by the drug. Any behavioral or physical changes which may be drug-related should be reported to the registered professional nurse. No Apparent Desired Effect: Different medications require different amounts of time before their effects are observable. For this reason the registered professional nurse tells you how long to expect it to take before the expected action can be seen. For example, if acetaminophen (Tylenol) was ordered every four hours for a fever, and 24 hours have gone by and fever remains unchanged, there is no apparent effect. Uses: Congestive heart failure or cardiac arrhythmias Purpose and Desired Effect: To slow and strengthen heartbeat. Unwanted or Side Effects: Nausea, diarrhea, vomiting, loss of appetite, pulse too slow. Think about any resident you know who may be taking ibuprofen (Nuprin, Advil, Motrin Ib), and decide if you can identify any of her or his behaviors or physical complaints that may be related to ibuprofen side effects. Performance Objective: Given at least three pharmacy labels, interpret with 100% accuracy, the information on each label identifying prescribed dosage, and instructions for when and how to administer the medication. Refer trainees to the handout included in the unit for Duty Area 2, Identifying A. Medication information: Review handout of generic versus brand names for common medications. Alternatively, the label may carry both the Have trainees interpret the labels generic name and the brand name, included in the practice section of the provided that the brand name is preceded handout. Provide feedback and further by the words generic substitute for, or explanation if indicated. Dispensed medication labels have the same information because it is required by law. If the generic name is used, the manufacturer or distributors name shall also appear; 6. Not required by law, but may be on the label: Number of times the drug may be re-ordered without a new prescription. One tablet daily in evening without regard to meal Cholesterol lowering diet recommended May cause photosensitivity report muscle pain or weakness to doctor. Generic medications are typically less expensive and manufactured under the generic or common name for the drug. Some manufacturers may even designate a brand or trade name for the generic product, a so-called branded generic. The New Jersey Generic Formulary is a list of interchangeable drug products which prescribers are encouraged to substitute. Enabling Objective: Determine the type of forms used at facilities to document medication administration. Complete medication documentation forms according Explain the importance of immediate and to facility procedure. Use to document each administration of Review handout material included in medication by resident. Highlight the most important information Pharmacist may provide an information sheet or on the sheet. Information should include a prescribers order, pharmacy label and any other information (real or simulated) required to amend medication forms used at a facility. Provide additional instruction for trainees who do not amend the documents with 100% accuracy. Medication Administration Record: Identify where each of the following elements of the Medication Administration Record is located: 1. Place for signature/initials of person assisting with administration of medication; 8. Write in the space below the name your facility uses to identify the form in which the administration of medication is recorded: When Re-fill Medication Arrives (Including Over-The-Counter Drugs): 1. Some facilities have a special form for "logging in" medications from the pharmacy. In other facilities the person who receives the medication from the pharmacy initials and dates the receipt to indicate that it has been reviewed and is correct. Do not give the medication until your questions are answered by the registered professional nurse. If the medication is a generic, its color and/or shape, and/or size may be different from what you have seen before. Explain any differences to the resident when the medication first comes from the pharmacy. Certain medications may require the pharmacist to order from other sources, which could delay dispensing time. Duty Area 6 Trainee Handout 74 When a New Medication (or Change in a Medications Dosage, Frequency, Form of Administration, Route of Administration, or Time) is Prescribed: 1. In some cases, the resident may return from the physician or prescribers office with a new written prescription or a newly filled prescription. Report the information from the prescription or pharmacy label to the registered professional nurse. Caution: Do not attempt to interpret a prescription if it is not absolutely clear. In those instances, send the prescription to the pharmacy and request that the registered professional nurse contact the pharmacy and/or practitioner who issued the prescription. In all instances, the certified medication aide should follow the facility policy regarding any discontinued or unused medications. Do not give a medication if you are uncertain about the correct dosage; call the registered professional nurse first. In some cases, the registered professional nurse may call to inform you that a medication has been discontinued; the resident should stop taking the medication. Report the information from the prescription label to the registered professional nurse. If allowable by regulation and/or facility policy, the registered professional nurse is to return any unused, discontinued medication to the pharmacy, or make arrangements with the resident to discard or remove the discontinued medication. Identifies the required elements of information required on a resident medication administration record.

He should never eat when tired or emotionally upset gastritis dieta order zantac with american express, nor when he is not hungry even if it is meal time gastritis migraine buy zantac line, nor when his mouth is dry gastritis diet trusted 150 mg zantac. However gastritis diet buy discount zantac 300mg, he should not drink water during or with meals diet bei gastritis cheap 300mg zantac with visa, but only half an hour before or one hour after he has eaten gastritis gurgling stomach generic zantac 150 mg fast delivery. Alternate hot and cold hip baths for 10 to 15 minutes and a mud pack applied over the lower abdominal for half an hour daily will help the ulcers to heal. The hip bath or the mud pack should be taken on an empty stomach and should be followed by a walk. In case of haemorrhage in the stomach, a rectal enema should be administered four times daily with water temperature at 110 to 115 o F. In case of abdominal or stomach pain, hot pack should be placed on the abdomen with water temperature at 120 o F. Asanas which are beneficial in the treatment of hyperacidity and ulcers are vajrasana, uttanpadasana, pawanmuktasana, bhujasana, paschimottanasana. Yogic kriyas like jalneti and pranayamas like anuloma-viloma, shitali and sitkari are also beneficial. Hyperacidity does not appear suddenly; it develops gradually and its cure is also a gradual process. The patient should not lose patience but must continue the regimen suggested; this will help him get relief from his ailment. They are a varicose and often inflammed condition of the veins inside or just outside the rectum. In some cases the veins burst and this results in what is known as bleeding piles. Symptoms Pain at passing stools, slight bleeding in the case of internal trouble and a feeling of soreness and irritation after passing a stool are the usual symptoms of piles. The patient cannot sit comfortably due to itching, discomfort and pain in the rectal region. Causes the primary cause of piles is chronic constipation and other bowel disorders. The pressure applied to pass a stool to evacuate constipated bowls and the congestion caused by constipation ultimately lead to piles. The use of purgatives to relieve constipation, by their irritating and weakening effect on the lining of the rectum, also result in enlargement and inflammation of veins and bleeding of the mucus lining. Piles are more common during pregnancy and in conditions affecting the liver and upper bowel. Prolonged periods of standing or sitting, strenuous work, obesity and general weakness of the tissues of the body are the other contributory causes of piles. The extra rectal pressure and the resultant congestion of veins ultimately leads to haemorrhoids. Treatment the treatment of the basic cause, namely, chronic constipation, is the only way to get rid of the trouble. To begin with, the whole digestive tract must be given a complete rest for a few days and the intestines thoroughly cleansed. For this purpose the patient should adopt an all-fruit diet for at least seven days. After the all-fruit diet, the patient may adopt a diet of natural foods aimed at securing soft stools. Three or four figs should be soaked overnight in water after cleansing them thoroughly in hot water. They should be taken the first thing in the morning along with water in which they were soaked. The tiny seeds of the fruit possess an excellent quality of stimulating peristalic movements of intestines. The pressure on the anus having thus been relieved, the haemorrhoids also get contracted. The seeds should be collected during the mango season, dried in the shade and powdered and kept stored for use as medicine. It should be given in doses of about one and a half gram to two grams with or without honey. The fruit should be taken with salt every morning for two or three months in its season. The use of the fruit in this manner in every season will effect a radical cure and save the user from bleeding piles during his / her entire life. White radish well ground into a paste in milk can also be beneficial applied over inflammed pile masses to relieve pain and swelling. The treatment is done by sitting in a tub filled with cold water for two minutes with knees drawn up to your chin. Other water treatments beneficial in curing piles include cold perennial douche and cold compress applied to the rectal area for an hour before bed time. Movements which exercise the abdominal muscles will improve circulation in the rectal region and relieve congestion. Outdoor exercises such as walking and swimming are excellent methods of building up general health. Yogic kriyas like jalneti and vamandhouti and asanas such as sarvangasana, viparit karani, halasana, gomukhasana are also useful. But premature greying is a morbid condition and it makes even the young look older. It is composed of the same kind of cells as are found in the outer layer of the skin, known as epidermis. The sebaceous glands of the scalp secrete an oily substance called sebum, which is the source of nutrition, lustre and blackness of the hair. The hair cannot be fed externally, for such nourishment as the scalp requires must come to it from the bloodstream. Causes of Greying A faulty diet and mental worries are the two primary causes of premature greying of hair. It is mainly due to the lack of some of the B vitamins, of iron, copper and iodine in the daily diet that this hair disorder is caused at a young age these days. Mental worries produce an extraordinary tension in the skin of the scalp which interferes with the supply of vital nutrition necessary for the health of the hair. Similarly, anxieties, fear, jealousy and failures have adverse effects on the hair. Other causes of premature greying of hair are unclean condition of the scalp which weakens the roots of the hair as the pores are blocked by the collected dirt; washing the hair with hot water and drying them with electric dryers which emit a blast of hot air; the use of hair dyes in the earlier stages when the hair have just started greying; diseases like chronic cold, sinusitis, anaemia, chronic constipation; and the use of factory made hair oils, which are generally cleaned with acids and some of the acids have a tendency to remain in the oil. Treatment Diet is of utmost importance in the prevention and treatment of premature greying of hair and persons suffering from this disorder should take a diet rich in all essential nutrients. To obtain satisfactory results, all three of these vitamins, belonging to B group, should be supplied at one time preferably in a form which gives all B vitamins, such as yeast, wheat germ and liver. The three anti-grey hair vitamins can be produced in the intestinal tract by bacteria. Thus drinking a litre of yogurt daily with a tablespoon of yeast before each meal will be an excellent remedy for the prevention and treatment of premature greying of hair. If one wishes to take tablets of calcium pantothenate and paba, they should be taken in addition to the yeast and yogurt and not as a substitute for them. Gayelord Hauser, one of the best known world nutritionists, in his book The New Diet Does it, claims that this treatment will restore the grey hair back to its natural colour. He also advises addition of iron and iodine in the form of sea food, to an otherwise adequate diet for obtaining better results. Besides fish, which is the main source of iodine, the requirement of this mineral can be met by adequate intake of carrots, bananas and similar other vegetables and fruits. Carrots are especially useful in furnishing fresh blood and maintaining the health of the hair. Home remedies Certain home remedies have been found useful in the prevention and treatment of premature greying of hair. The foremost among these is the use of Indian gooseberry or amla which is a valuable hair tonic for enriching hair growth and hair pigmentation. The water in which dried amla pieces are soaked overnight is Indian gooseberry (amla) is considered highly beneficial in the treatment of premature greying of hair. Massaging the scalp with a teaspoonful of amla juice mixed with a teaspoonful of almond oil or few drops of lime juice, every night has proved beneficial in the prevention and treatment of premature greying of hair. Liberal intake of curry leaves is considered beneficial in preventing premature greying of hair. The leaves can be used in the form of chutney or these may be squeezed in butter milk or lassi. When the leaves are boiled in coconut oil, the oil forms an excellent hair tonic to stimulate hair growth and bring back hair pigmentation. The butter made from cows milk has the property to prevent premature greying of hair. A small roll may be taken internally and a little quantity may be massaged into the hair root twice a week. Ribbed gourd, known as torai in the vernacular, boiled in coconut oil is another effective remedy for premature greying of hair. These dried pieces should be soaked in coconut oil and kept aside for three or four days. Hair Dye the paste of henna leaves, boiled in coconut oil to get a darkish oil, can be used as a hair dye to blacken grey hair. The paste itself can be applied to the hair and washed away after a few hours to dye the grey hair. Washing the hair with concentrated tea extract twice a week is also considered useful in colouring grey hair to brown or black. Prostate and bladder disorders can lead to numerous other ailments such as arthritis, kidney disorders and uremia. The prostate gland is a male gland, comparable in shape and size to a large chestnut. It is situated at the base of the urinary bladder and around the commencement of the urethra, the membranous tube for the passage of the urine. It is thus vital in relation to the emptying of the bladder and bears a close relationship to the rectum. The gland plays an important role in normal sexual life and its function is to secrete a fluid which is added to semen during sexual intercourse. Of these the most important are prostatitis or inflammation in the prostate gland and hypertrophy or enlargement of the prostate gland. It is a painful and distressing disorder, but can be cured with proper treatment without any adverse effects. Enlargement of the prostate gland or hypertrophy is the most common complaint affecting the gland. The enlargement develops so gradually over a long period that it often assumes serious proportions before it is detected. Symptoms There are two warning signals to indicate the possibility of prostate disorders. The first is the interface with the passage of urine and the second is the need to void the urine frequently during the nights sleep. Other symptoms are a dull aching pain in the lower back and pain in the hips, legs and feet. The patient experiences all the symptoms of disturbed health such as lack of energy and physical, mental and nervous disturbances. Causes the position of the prostate gland makes it liable to congestion and other disorders. In an erect position, pressure falls on the pelvic region just where the prostate gland is situated. With ageing, the body gets heavier and loses its flexibility which makes the pressure on the pelvis even greater and increases the vulnerability of the prostate gland. Prolonged periods of sitting down, as in certain occupations, also increases the pressure on the pelvic region resulting in congestion of the tissues in and around the prostate gland. With the passage of time, changes such as inflammation or enlargement occur in the gland. Acute prostatis may also result from exposure to cold and chill and from an infectious disease. It may also result from continual irritation of the gland due to excessive sexual excitement. In constipation, the faeces becomes hardened and the rectum or lower bowel overloaded. It also entails a great deal of straining at stools and this adversely affects the prostate gland due to its proximity to the rectum. Treatment To begin with, the patient should forgo all solid foods and subsist on water only for two or three days. The water may be taken cold or hot and it should be taken every hour or so when awake. An enema may be taken once a day during fasting to clear the lower bowel of accumulations. The hot bath should be taken first for 10 minutes, followed by a cold bath for one minute daily. The fruits should include apples, pears, oranges, grape-fruit, grapes, sweet limes, mangoes, melons and all other juicy fruits. This will help to clear toxins from the body and will also enable excess fat to be reduced to some extent. The exclusive fruit diet should be followed by a diet, consisting of two meals of fruits and one of cooked vegetables for further seven days. The vegetable meal should be taken in the evening and should consist of all kinds of cooked vegetables, preferably steam cooked. Thereafter, the patient may adopt a well-balanced diet of three basic food groups, namely (i) seeds, nuts and grains, (ii) vegetables and (iii) fruits. The short lemon juice fast followed by an all-fruit diet and a further period on fruits and vegetables may be repeated after two or three months if necessary depending on the progress being made.

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She states that with cough she may occa sionally lose some urine; otherwise she has no complaints gastritis in pregnancy purchase 150 mg zantac overnight delivery. What type of speculum would be most appropriate to gastritis losing weight order zantac cheap online use when performing this patients Pap test She uses oral contraceptive pills and denies any history of an abnormal Pap smear gastritis diet buy zantac 150mg online. The cyst is nontender and does not cause the patient any dyspareunia or discomfort gastritis nexium zantac 300 mg on-line. She tells you that about 10 years ago she was treated with a laser conization for carci noma in situ of her cervix gastritis diet 3121 order cheapest zantac. What recommendation should you make regarding how frequently she should undergo Pap smear testing She had three vaginal deliveries gastritis gallbladder removal generic 150mg zantac with amex, the last of which was complicated by gestational diabetes and preeclampsia. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. A 30-year-woman presents to your office with the fear of developing ovarian cancer. Currently she and her husband use condoms, but they hate the hassle of a coital-dependent method. She is interested in a more effective contraception because they do not want any more children. She reports occasional migraine headaches and had a serious allergic reaction to anesthesia as a child when she underwent a tonsillectomy. During her office visit, you counsel the patient at length regarding birth control methods. Which of the following is the most appropriate contraceptive method for this patient Her family history is significant for stroke, dia betes, and high blood pressure. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and tem perature 37C (98. The next appropriate step in the management of this patients blood pressure is which of the following Nicotine replacement in the form of chewing gum or transdermal patches has not been shown to be effective in smoking cessation programs. No matter how long one has been smoking, smoking cessation appears to improve the health of the lungs. Alternatively, flexible sigmoidoscopy can be performed every 5 years along with a yearly fecal occult blood test. After a woman has had three or more con secutive normal Pap smears, the Pap test may be performed less frequently in a low-risk woman. A hepatitis B vaccine would be indicated only in individuals at high risk (ie, international travelers, intravenous drug users, and their sexual contacts, those who have occupational exposure to blood or blood products, persons with chronic liver or renal disease, or residents of institutions for the devel opmentally disabled, and inmates of correctional institutions). Parabasal cells on a Pap smear indicate lack of estrogen and are a normal finding in postmenopausal women. Hepatitis C virus testing is indicated only in persons with a history of injecting illegal drugs, those who have received blood transfusions before 1992, those with occupational exposure to blood products, or those undergoing chronic hemodialysis. She is not a candidate for the varicella Preventive Care and Health Maintenance Answers 193 vaccine since she has had chicken pox. The hepatitis A vaccine is indicated for international travelers, illegal drug users, and health care workers. The pneumococcal vaccine is indicated in immunocompromised persons, those with chronic illnesses, and individuals more than 65 years old. The influenza vaccine is especially indicated in pregnant women, individuals with chronic diseases, and those in long-term-care facilities. It is best to perform the breast examina tion in both the erect and supine positions. Asymmetry of the breasts is common in most women, but any recent changes need to be reported. Any nipple discharge should be reported immediately to a physician, because it can be associated with an underlying tumor. The Pederson speculum works best for nulliparous women and menopausal women with atrophic vaginas; the blades are flat and narrow and barely curve on the sides. The blades of the Graves speculum are wider, higher, and curved on the sides; they work better for parous women with looser vaginal walls. A childs vagina can best be examined using an instrument called a vaginoscope or some type of endoscope such as a hysteroscope. The Graves and Pederson speculums come in pediatric sizes to be used in virginal adults or young chil dren. Nasal specula are too short to be used to examine the vagina in adults and children. More specifically, the parity is further subclassified into number of term deliveries, preterm deliveries, abortions (spontaneous or induced) or ectopics, and number of living children. Since this patient is a G6P3215, she has been pregnant six times and has had three term deliveries, two preterm deliveries, one abortion, and has five liv ing children. Pederson specula have nar rower blades and are most appropriate for nulliparous patients and post menopausal patients with atrophic vaginas. Pediatric specula, vaginoscopes, and hysteroscopes are all used to examine infants or prepubertal children. These are usually small and asymptomatic and are found inci dentally during a pelvic examination. They can be followed conservatively unless the patient becomes symptomatic, at which time excision is recom mended. Inclusion cysts are the most common vaginal cysts and result from birth trauma or previous gynecologic surgery. Bartholin ducts open into a groove between the hymen and labia minora on the posterior lateral vaginal open ing. Lipomas are benign, encapsulated tumors of fat cells; they are most commonly discovered in the labia majora and are superficial in location. Hematomas of the vulva usually occur as a result of blunt trauma or strad dle injury. Spontaneous hematomas can occur as a result of rupture of a varicose vein in pregnancy or the postpartum period. This patient is not considered to be a low-risk patient since she Preventive Care and Health Maintenance Answers 195 has a history of previous cervical pathology. This patient is at an increased risk of developing diabetes because she experienced ges tational diabetes during pregnancy. With her previous history of treatment for cervical dysplasia, yearly Pap smear is recommended. The use of combination oral contraceptives decreases the risk of developing ovarian cancer by about 40%. Nulliparity, increasing age, and fertility drugs all increase ovulatory cycles and therefore are risk factors for developing ovarian cancer. In the general population, the risk of developing ovarian cancer is about 1% to 1. This risk increases to about 5% if a woman has one first-degree relative with ovarian cancer and to about 7% if she has two or more first degree relatives with ovarian cancer. A bilateral tubal ligation would be another option; how ever, the patient had a serious allergic reaction to anesthesia as a child, and general anesthesia is required for female laparoscopic sterilization. The patients smoking and age contraindicate the use of combination oral contra ceptives. Migraine headaches accompanied by neurologic symptoms such as loss of vision, paresthesias, and numbness are generally considered to be a contraindication to combination oral contraceptive use. However, there are no studies that show a statistically significant increased risk of stroke in pill users who have migraine headaches. Use of a diaphragm is a coital-dependent action and the patient relates that that is not something she desires. A single ele vated diastolic blood pressure less than 100 mm Hg should be treated, but should be rechecked within 2 months. The first line of treatment for women with hypertension should be lifestyle changes: smoking cessation, weight loss, diet modification, stress management, and exercise. If after 3 months these measures have failed to lower blood pressure, then pharmacologic therapy should be instituted. There are studies that demonstrate that smoking cessation is of ben efit to pulmonary health regardless of how long one has smoked. Doctors should repeatedly counsel their patients to stop smoking, and follow-up visits to achieve these goals are effective. Nicotine replacement therapy and transdermal nicotine patches have increased the effectiveness of smoking cessation programs. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus Ultrasound confirms a com plex left adnexal mass with solid components that appear to contain bone and teeth. At exploratory laparotomy, a unilateral ovarian neoplasm is discov ered that is accompanied by a large omental metastasis. Omentectomy, total abdominal hysterectomy, and bilateral salpingo-oophorectomy 274. At the time of pelvic examination, a mildly tender, fluctuant mass is noted just outside the introitus in the right vulva in the region of the Bartholin gland. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The patient above now asks you for your advice on how to treat her cervical disease. A woman is found to have a unilateral invasive vulvar carcinoma that is 2 cm in diameter but not associated with evidence of lymph node spread. Radical vulvectomy and bilateral inguinal lymphadenectomy 200 Obstetrics and Gynecology 279. A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. Which of the following tissues within this radiation field is the most radiosensitive A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies Stage Ib cervical cancer is diagnosed in a young woman who wishes to retain her ability to have sexual intercourse. Assuming that the cancer is confined to the cervix and that intraoperative biopsies are negative, which of the following structures would not be removed during the radical hysterectomy The upper third of the vagina Benign and Malignant Disorders of the Breast and Pelvis 201 283. A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the fol lowing sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. In this patient, lymphatic drainage characteristically would be first to which of the follow ing nodes A 17-year-old girl is seen by her primary care physician for the eval uation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. A 41-year-old woman undergoes exploratory laparotomy for a per sistent adnexal mass. Assum ing that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy Which of the following histologic findings is consistent with the diagnosis of lichen sclerosus A 21-year-old woman returns to your office for evaluation of an abnormal Pap smear. On physical examination the patient has multiple 2 to 10-mm lesions around her introitus consistent with condyloma. Which of the following viral types is most likely responsible for the patients condyloma A 26-year-old G2P1 presents to the gynecologist complaining of increasing hair growth on her face, chest, and abdomen, but the hair on her head is receding in the temporal regions. On physical examination the patient has significant amounts of coarse, dark hair on her face, chest, and abdomen. A 67-year-old woman is found to have bilateral adnexal masses while undergoing evaluation of her recently diagnosed colon cancer. A 17-year-old woman is referred by her primary care physician for the evaluation of primary amenorrhea. A 19-year-old woman is undergoing exploratory laparotomy for a 9-cm right ovarian mass. The final pathology report shows evidence of glial tissue and immature cerebellar and cortical tissue.

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Information on the two propellants is as follows: property propane iSoButane Molecular formula C3H8 C4H10 Molecular weight 44 gastritis zungenbelag order zantac 150 mg otc. From Raoult law gastritis diet generic zantac 150 mg, the partial pressure exerted by the propane is Ppropane = n propane / n propane + n isobutane Ppropane Ppropane = (13) (36 + 0691) 10 = 72 98 gastritis en ingles purchase zantac 300 mg without a prescription. The partial pressure exerted by the isobutane is Pisobutane = (06) (36 + 06) 04= 10 23 5 gastritis flare up generic 300mg zantac with amex. Pressure is applied the physical form selected for a given aero to gastritis headache generic zantac 150mg amex the aerosol system through the use of one sol is based on intended use gastritis diet purchase zantac uk. The design of the deliv 3 1 ery system is intended to release measured <1 quantities and of the appropriate quality of the active substance with each actuation. By contrast, the par tion of the valve releases measured mass and ticle size for a dermatologic spray intended appropriate quality of the active substance. The design of the delivery present the medication in the form of a pow system releases one dose with each actuation. Other pharmaceutical aerosols include aerosol drug products may be designed, as vaginal and rectal foams. Room disinfec valve or continuous release of formulation tants, room deodorizers, and space insec during depressed status of the valve. The particle size of the released product is advantages of the aerosol Dosage generally quite small, usually below 50 m, Form and must be carefully controlled so that the Some features of pharmaceutical aerosols that dispersed droplets or particles remain air may be considered advantages over other borne for a long time. A 1-second burst from types of dosage forms are as follows: a typical aerosol space spray will produce 120 million particles, a substantial number 1. A portion of medication may be easily of which will remain suspended in the air withdrawn from the package without con for an hour. The dermatologic aerosols sol container protects medicinal agents can be placed in this group. Also included are adversely affected by atmospheric oxygen a great many cosmetic and household aero and moisture. Being opaque, the usual aero sol products, including personal deodorant sol container also protects drugs adversely sprays, hair lacquers and sprays, perfumes affected by light. This protection persists and colognes, shaving lathers, toothpaste, during the use and the shelf life of the prod surface pesticide sprays, paint sprays, spray uct. If the product is packaged under aseptic starch, waxes, polishes, cleaners, and lubri conditions, sterility may also be maintained cants. Topical medication may be applied in a uni such food products as dessert toppings and form thin layer to the skin without anything food spreads. By proper formulation and valve control, prohibited for nonessential use under federal the physical form and the particle size of regulations following recognition that they the emitted product may be controlled, reduce the amount of ozone in the strato which may contribute to the efficacy of a sphere, which results in an increase in the drug, as with the fine controlled mist of amount of ultraviolet radiation reaching the an inhalant aerosol. Through the use of earth, an increase in the incidence of skin can metered valves, dosage may be controlled. A num When the propellant is a liquefied gas or ber of metered-dose pharmaceutical prod a mixture of liquefied gases, it frequently ucts for oral inhalation have received such serves the dual role of propellant and solvent essential use exemptions. In cer used as propellants in pharmaceuticals were tain aerosol systems, compressed gasescar dichlorodifluoromethane, dichlorotetrafluo bon dioxide, nitrogen, and nitrous oxideare roethane, and trichloromonofluoromethane employed as the propellant. The numeric designations are arrived at by the following method: (a) the digit at the extreme right refers to the number of fluorine atoms in the molecule. The number of chlorine atoms in a molecule may be determined by subtracting the total number of hydrogen and fluorine atoms from the total number of atoms which may be added to the carbon chain. They may be liquefied by of the drop in pressure, leaving the product cooling below their boiling point or by com concentrate as airborne liquid droplets or pression at room temperature. For example, dry particles, depending upon the formula dichlorodifluoromethane (Freon 12) will tion. As the liquid phase is removed from form a liquid when cooled to 30C (22F) the container, equilibrium between the pro or when compressed to 70 psig (pounds pellant remaining liquefied and that in the per square inch gauge) at 21C (70F). Thus, even dur of these methods for liquefying gases are ing expulsion of the product from the aerosol employed in aerosol packaging, as discussed package, the pressure within remains virtu later in this section. However, when the liquid container with the product concentrate, equi reservoir is depleted, the pressure may not librium is quickly established between the be maintained, and the gas may be expelled portion of propellant that remains liquefied from the container with diminishing pres and that which vaporizes and occupies the sure until it is exhausted. The vapor phase exerts pressure in aerosol systems all directionsagainst the walls of the con tainer, the valve assembly, and the surface of the pressure of an aerosol is critical to its per the liquid phase, which is composed of the formance. Thus, aerosol valve, forces the liquid phase up the each formulation is unique unto itself, and a dip tube and out of the orifice of the valve specific amount of propellant to be employed into the atmosphere. Space sprays generally contain ingredient of a formulation are nontoxic a greater proportion of propellant than do when tested individually, the use of the com aerosols intended for surface coating; hence, bination in aerosol form may have undesir they are released with greater pressure, and able features. For instance, when an active the resultant particles are projected more ingredient ordinarily used in a nasal or oral violently from the valve. Space aerosols usu spray is placed in a fine aerosol mist, it may ally operate at 30 to 40 psig at 21C and may reach deeper into the respiratory tract than contain as much as 85% propellant. With new der aerosols commonly contain 30% to 70% pro matologic, vaginal, and rectal aerosol prod pellant with pressures between 25 and 55 ucts, the influence of the aerosol form of the psig at 21C. Foam aerosols usually operate drug on the recipient tissue membranes must between 35 and 55 psig at 21C and may con be evaluated for irritating effects and changes tain only 6% to 10% propellant. The absorption pattern of a drug emulsions because the liquefied propellant may change because of an increased rate of is partially emulsified with the product con solubility of the fine particles usually pro centrate rather than being dissolved in it. Because the fluorinated hydrocarbons are Although the fluorinated hydrocarbons nonpolar organic solvents having no affinity have a relatively low order of toxicity and for water, the liquefied propellant does not are generally nonirritating, certain individu dissolve in the aqueous formulation. The use als who use an inhalation aerosol may be of surfactants or emulsifiers in the formula sensitive to the propellant agent and may tion encourages the mixing of the two compo exhibit cardiotoxic effects following rapid nents to enhance the emulsion. Two-phase Systems When the aerosol valve is activated, the mix As noted previously, the two-phase aerosol ture is expelled to the atmosphere, where the system consists of the liquid phase, contain propellant globules vaporize rapidly, leaving ing the liquefied propellant and product con the active ingredient in the form of a foam. Blends of the various liquefied gas propel lants are generally used in pharmaceutical Three-phase Systems aerosols to achieve the desired vapor pres the three-phase system consists of a layer of sure and to provide the proper solvent fea water-immiscible liquid propellant, a layer of tures for a given product. Some propellants highly aqueous product concentrate, and the are eliminated from use in certain products vapor phase. Because the liquefied propellant because of their reactivity with other formu usually has a greater density than the aque lative materials or with the proposed con ous layer, it generally resides at the bottom of tainer or valve components. For instance, the container with the aqueous phase float trichloromonofluoromethane tends to form ing above it. As with the two-phase system, free hydrochloric acid when formulated with upon activation of the valve, the pressure of systems containing water or ethyl alcohol, the vapor phase causes the liquid phase to the latter a commonly used cosolvent in aero rise in the dip tube and be expelled from the sol systems. To avoid expulsion of the reservoir only affects the efficacy of the product but of liquefied propellant, the dip tube must also corrodes some container components. The aqueous product aerosol to ensure safety of the product in its is broken up into a spray by the mechanical intended use. The vapor phase Containers within the container is replenished from the Various materials have been used in the liquid propellant phase. The pressure of tion of the container for an aerosol product is the compressed gas in the head space of the based on its adaptability to production meth aerosol container forces the product concen ods, compatibility with formulation compo trate up the dip tube and out of the valve. The nents, ability to sustain the pressure intended use of gases that are insoluble in the prod for the product, the interest in design and uct concentrate, as is nitrogen, will result aesthetic appeal on the part of the manufac in emission of a product in essentially the turer, and cost. Were it not for their brittleness and dan An advantage of nitrogen as a propellant is ger of breakage, glass containers would be its inert behavior toward other formulative preferred for most aerosols. Glass presents components and its protective influence on fewer problems with respect to chemi products subject to oxidation. Also, nitrogen cal compatibility with the formula than do is an odorless and tasteless gas and thus does metal containers, and it is not subject to cor not contribute adversely to the smell or taste rosion. On the negative side, glass Other gases, such as carbon dioxide and containers must be precisely engineered to nitrous oxide, which are slightly soluble in provide the maximum in pressure safety the liquid phase of aerosol products, may and impact resistance. Plastic coatings are be employed when their expulsion with the commonly applied to the outer surface of product concentrate is desired to achieve glass containers to render them more resis spraying or foaming. Thus, total pressure of an aerosol system is below higher gas pressures are required in these 25 psig and no more than 50% propellant is systems, and the pressure in these aerosols used, glass containers are considered quite diminishes as the product is used. When required, the inner surface of glass containers may be coated to render them more chemically resistant to formula aerosol container and Valve tion materials. When cally interact with the container or valve required, special protective coatings are components so as to interfere with the stabil employed within the container to prevent ity of the formulation or with the integrity corrosion and interaction between the con and operation of the container and valve tainer and formulation. M ounting Most aluminum containers are manu Stem cup factured by extrusion or by other methods Housing Gasket that make them seamless. They have the Spring advantage over the seam type of container of greater safety against leakage, incompatibil ity, and corrosion. Stainless steel is employed to produce containers for certain small-vol ume aerosols in which a great deal of chemi Dip cal resistance is required. Plastic containers have met with varying success in the packaging of aerosols because of their inherent problem of being perme ated by the vapor within the container. Also, certain drugplastic interactions affect the release of drug from the container and reduce the efficacy of the product. Stem: supports the actuator and delivers the function of the valve assembly is to per the formulation in the proper form to the mit expulsion of the contents of the can in the chamber of the actuator desired form, at the desired rate, and in the 3. Gasket: placed snugly with the stem and case of metered valves, in the proper amount prevents leakage of the formulation when or dose. The materials used in the manufac the valve is closed ture of valves must be inert to the formula 4. Mounting cup: attached to the aerosol can the usual aerosol valve assembly is com or container and holds the valve in place. Actuator: the button the user presses to cup is exposed to the formulation, it must activate the valve assembly for emis receive the same consideration as the inner sion of the product. The actuator permits part of the container with respect to meet easy opening and closing of the valve. If necessary, is through the orifice in the actuator that it may be coated with an inert material the product is discharged. Housing: Directly below the mounting the physical form (mist, coarse spray, solid cup, the housing links the dip tube and stream, or foam) in which the product is the stem and actuator. The type and quantity of pro orifice helps to determine the delivery pellant used and the actuator design and rate and the form in which the product is dimensions control the particle size of the emitted. Dip tube: extends from the housing down propellant) are used for products to be into the product; brings the formulation emitted as foams and solid streams than from the container to the valve. Depression of the the actuator, stem, housing, and dip tube are actuator causes a simultaneous reversal of generally made of plastic, the mounting cup positions; the chamber becomes open to the and spring of metal, and the gasket of rubber atmosphere, releasing its contents, at the same or plastic resistant to the formulation. Upon release of the actuator, the Metered-Dose inhalers system is restored for the next dose. In these metered As noted previously, the effectiveness of valve systems, the amount of material dis delivering medication to the lower reaches of charged is regulated by an auxiliary valve the lungs for local or systemic effects depends chamber by virtue of its capacity or dimen in part on the particle size of the inhaled drug. A single depression of the actua Breathing patterns and the depth of respira tor causes evacuation of this chamber and tion also play important roles in the deposi delivery of its contents. Analysis chamber is controlled by a dual valve mech of dose uniformity (11), particle size distribu anism. When the actuator valve is closed, tion patterns (1214), and the respirable frac tions of aerosol-delivered particles (15, 16) are areas of research in developing aerosol prod ucts for optimal oral inhalation therapy. A unique translingual aerosol formula tion of nitroglycerin (Nitrolingual Spray, Rhone-Poulenc Rorer) permits a patient to spray droplets of nitroglycerin onto or under the tongue for acute relief of an attack or for prophylaxis of angina pectoris due to coronary artery disease. The product contains 200 doses of nitroglyc erin in a propellant mixture of dichlorodiflu oromethane and dichlorotetrafluoroethane. Filling operations As explained earlier, fluorinated hydrocar bon gases may be liquefied by cooling below their boiling point or by compressing the gas at room temperature. Each metered dose is delivered through the mouthpiece upon actua In the cold method, both the product con tion of the aerosol units valve. The cooling system may be a mixture of dry ice and acetone or a more elab orate refrigeration system. After the chilled product concentrate has been quantitatively metered into an equally cold aerosol con tainer, the liquefied gas is added. The heavy vapors of the cold liquid propellant generally displace the air in the container. When sufficient propellant has been added, the valve assembly is inserted and crimped into place. For nonaqueous systems, some moisture usually appears in the final product due to the condensation of atmo the filling apparatus through the use of com spheric moisture within the cold containers. The trapped air in the package may be ignored if it does not pressure Filling interfere with the quality or stability of the By the pressure method, the product concen product, or it may be evacuated with a spe trate is quantitatively placed in the aerosol cial apparatus. This spray test uefied gas, under pressure, is metered into ing also rids the dip tube of pure propellant the valve stem from a pressure burette (Fig. The desired amount of propellant is Pressure filling is used for most pharma allowed to enter the container under its own ceutical aerosols. When the pressure in the cold filling: There is less danger of moisture container equals that in the burette, the pro contamination of the product, and less pro pellant stops flowing. Prior to filling, the prod uct concentrate is placed in the container, the valve assembly is crimped into place, and the air is evacuated from the container by a vacuum pump. The compressed gas is then passed into the container through a pressure-reducing valve attached to the gas cylinder; when the pressure within the aero sol container is equal to the predetermined and regulated delivery pressure, the gas flow stops, and the aerosol valve is restored to the closed position. For gases like carbon dioxide and nitrous oxide, which are slightly soluble in the product concentrate, the container is Figure 14. Exposure to temperatures above 49C (120F) may Testing the Filled Containers burst an aerosol container. Most medications After filling by either method, the aerosol in aerosol containers are intended for use at container is tested under various environ ambient room temperatures. When the can mental conditions for leaks or weakness in isters are cold, less than the usual spray may the valve assembly or container. This may be particularly important Filled aerosol containers are also tested to users of metered-dose inhalation sprays. The valve these products are generally recommended discharge rate is determined by discharg for storage between 15C and 30C (59F and ing a portion of the contents of a previously 86F). Pharmaceutical aerosols are labeled weighed aerosol during a period and calcu with regard to shaking before use, holding lating, by the difference in weight, the grams at the proper angle and/or distance from the of contents discharged per unit of time.

References:

  • https://doi.org/10.1111/ajt.15611
  • https://dev.org.es/analysis/order-online-ofloxacin-no-rx/
  • https://www.kidney.org/sites/default/files/docs/ckd_evaluation_classification_stratification.pdf

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