Digoxin

Cases Case 1 A 69-year-old woman is admitted with right upper quadrant pain and tenderness and known gallstones found incidentally during an ultra- sound for uterine fibroids buy digoxin 0.25 mg fast delivery. Subsequent to the diagnosis generic digoxin 0.25 mg amex, she had an attack of biliary colic requiring an outpatient visit to her local emer- gency room. Her blood work in the emergency room included a fasting blood glucose level that was elevated at a level of 240mg/dL. Out- patient blood testing prior to her surgery revealed a direct bilirubin level of 3. Case 2 You are a third-year medical student beginning your third-year clerk- ship with surgery. You are instructed by the course director to have the chief resident orient you to your duties. The chief resident tells you to come to the operating room quickly to help on an emergency opera- tion. Some sur- geons are putting on shoe covers while others are putting on dirty, old running shoes and not using shoe covers. The head nurse tells you that you are in violation of hospital code by not wearing a head cover in the hallways outside the operating room. When you reach the operat- ing room, the surgeon and the chief resident already are at the operat- ing table, having washed their hands for less than 2 minutes. Case 3 An obese 55-year-old man had an emergency colectomy for perforated diverticulitis. At surgery, a large segment of sigmoid colon was involved with the infectious process. The colon was thickened by chronic inflammation, surrounded by a watery exudate, with omentum and small bowel adherent to the sigmoid colon. The patient had no significant medical history, but on admission he had significant hyper- tension and a blood sugar of 340mg/dL. The wound was closed, including the skin, and the patient was transferred to the intensive care unit. Now, on postoperative day three, he is febrile with a peak tem- perature of 39°C (102. Introduction Control of infection in the surgical patient should be considered in three components as indicated in Algorithm 6. The preoperative (pre- hospital) component consists of whatever medical conditions the patient brings to the hospital. Evaluation of this component dictates a careful review of the patient’s general health, so that appropriate antibiotics, when necessary, may be administered in a timely fashion. Other health conditions, such as smoking, should be stopped so that they have minimum effect during the surgical procedure. In this component, the timing of antibiotics and possible re-dosing of antibiotics need to be considered. The transmission of resistance organisms or the particular infestation of a highly virulent organism is the factor that determines whether a patient develops an infection. For this compo- nent, the surgeon needs to consider the antibiotic sensitivities so that proper antibiotics are given. An infection manifests itself when local or systemic host factors, environmental factors, and the microbes overwhelm the host. The risk factors for developing a wound infection: the susceptibility of the host, the vir- ulence of the invasive bacteria, and the environmental conditions in which the wound is made. The wound needs to be assessed with respect to the post- operative signs of sepsis, specifically, fever, elevated white blood count, wound erythema, and wound tenderness. An early diagnosis of a postoperative infection can minimize its impact on the speed of recuperation. Delay in the diagnosis and management of an infection can result in devastating, if not life-threatening, complications. Preoperative Antibiotics The second half of the 20th century ushered in the “antibiotics era. Consequently, for antibiotics to work effectively, they have to be “on board” at the time of this inoculation in order to prevent the infection. The risk that any postoperative wound will get infected is based on the complexity and duration of the operation. Since clean operations do not violate bacterial-bearing organs, the infection rate is very low. A wound classification system was devised in the 1970s that identifies the infection risk following surgery. Clean Cases Prophylactic antibiotics generally are not recommended for those patients having clean operative procedures, since the minimal benefit that might result is equivalent to the risk of a side effect from the antibiotic.

In addition to George’s construction of being “sick” without medication purchase 0.25 mg digoxin amex, in the second extract buy digoxin 0.25mg with mastercard, Ryan also appeals to the biomedical model of mental illness through his description of medication treating “that chemical imbalance in your mind”. As before, medication is constructed here as alleviating this illness or abnormality: Despite side effects (“sedating, a bit tiring and lack of energy”), through its efficacy in treating the “chemical imbalance”, medication allows an individual to “turn to normal”. Through Ryan’s reference to these side effects, followed by his construction of medication as a normalizing agent, it is suggested that the experience of side effects does not compromise the ‘normal’ status of consumers despite antipsychotic medication side effects being absent from the ‘normal’, mentally healthy human experience. In the following extracts, Ross and Steve associate their adherence with medication’s effectiveness in reducing the risk of suicide. This is contrasted with suicidal tendencies when symptoms were left untreated by 181 medication. They thereby construct medication adherence as enabling them to live: Ross, 14/08/2008 L: What sorts of things do you find that you um, are you able to enjoy now that you couldn’t if you weren’t on medication? Above, Ross indicates that he would not be able to “cope” and “wouldn’t be alive today” without medication. He implies that he experienced suicidal tendencies when symptomatic and untreated. Steve elaborates that “the voices would take over” which he would “act on” by committing “suicide”. Both Ross and Steve highlight the importance of the efficacy of their medication in reducing their symptoms, particularly given that when symptomatic, they become suicidal. Whilst neither of them directly link their 182 adherence with their medication’s capacity to reduce the risk of suicide, both could be seen to imply that adherence is a logical choice when their negative experiences associated with non-adherence are taken into account. In the following extracts, consumers highlight how by treating their symptoms, medication improves their lives. They construct the by-products of medication adherence, including symptom relief, cognitive, emotional and social gains, as reinforcing adherence: Anna, 18/02/2009 L: What would be then the main benefits I guess of taking your medication then? A: Well I seem to have um, a more meaningful life um, I’m able to socialize um, and make decisions for myself. A: More so the right decision rather than, anything went before; what happened, happened and yeah, never really thought of the consequences before. I mean, I get agitated when I’m unwell and that but the medication, I truly believe the medication helps keep me well. Anna and Rachel both refer to experiences of non-adherence and contrast this with experiences of adherence to emphasise how, by treating their symptoms, medication has changed them and rendered their lives more “meaningful” or fulfilling. Anna contrasts a lack of understanding of consequences when non-adherent to improved decision-making skills when adherent. Anna also contrasts a pre-adherence “couldn’t give a shit attitude” with enhanced consideration of others when adherent. Rachel explicitly links taking medication to keeping her “well”, implies an association between non- adherence and being “unwell”, and could be seen to construct reduced agitation and anger as signifiers of wellness and thus, medication’s efficacy. Rachel emphasizes personal improvements associated with adherence by referring to herself as a “better” person and mother generally. It is implied in the extracts above that other people may also benefit from the changes the consumers attribute to adherence. For example, improvements in social skills and enhanced consideration of others may improve Anna’s interactions with others and it could be logically argued that Rachel’s children would benefit from her improved parenting ability. In the following extract, Gary and Ruth talk about what leading a more ‘normal’ life when taking medication entails for them: Gary and Ruth, 31/07/2008 G: Yeah, well prob-…oh, just feeling better is the main thing an’…um, being able to live, live just a normal life and stuff to some degree, isn’t it? G: Just live a normal life, because if she didn’t have her medication she’d be having her panic attacks an’ L: Yeah. She’d be hospitalised all the time instead of living life at home like we are now and having a bit of a normal life. L: So what sort of things would that involve, like what do you mean when you say a normal life? This is implied through his description of a “normal life” as entailing the absence of symptoms such as anxiety, agitation, hallucinations and delusions of reference (i. Gary’s construction of a “normal life” appears to relate to accepted conceptions of the positive symptoms of schizophrenia as additional to consumers’ usual repertoire of feelings. By highlighting how these symptoms interfere with day to day activities, such as watching television, Gary underscores the pervasive life impact of active schizophrenia symptoms and constructs medication adherence as bridging the gap between the lifestyles of the mentally ill and the mentally healthy by addressing these additional experiences. Importantly, despite the repeated references to a “normal life” and normality in this extract, these descriptions are sometimes hedged: “a normal life … to some degree”, “a bit of a normal life”. These descriptions can be seen to highlight that there are measures of medication’s efficacy in treating symptoms. For example, in this instance, it may not completely alleviate symptoms, accounting for the hedged constructions of a “normal life”. Additionally, the distinction between being mentally ill and mentally healthy is not always clear-cut. In the next extract, in the context of discussing what motivates him to be adherent, George directly posits that “being able to do things that other people are able to do without being limited by mental illness” influences his adherence. This quote directly reflects how some consumers framed mental 186 illness as limiting or detracting from their lives and, thus, constructed medication, through its efficacy in treating symptoms, as addressing limitations associated with mental illness.

Atopic diseases (which are a form of 294 allergy) where the hypersensitivity reaction occurs at a location different from the initial contact point between the body and the offending agent generic digoxin 0.25mg line, and it also can alleviate Raynaud’s disease (which is characterized by periods of disrupted blood flow to the fingers and sometimes toes order 0.25 mg digoxin with mastercard, caused by exposure to cold and stress. Progesterone inhibits through positive feedback, the secretion of pituitary gonadotrophins, in turn, this prevents follicular maturation and ovulation or alternatively promotes it for the prime follicle. Occasionally noted with short-term dosage, frequently observed with prolonged high dosage. Assess for any thrombophlebitis, pulmonary embolism, cardiac, liver, or renal dysfunction, cerebral hemorrhage, breast or genital cancers 296 2. Gastric distress usually subsides after the first few cycles of the drug, report if these symptoms persist. Report any symptoms of thrombic disorders such as pains in the legs, sudden onset of chest pain, and shortness of breath or coughing. Report any yellowing of the skin or eyes, which may necessitate discontinuing the drug, evaluation of liver function tests, and possibly a dosage change. May worsen psychic depression; report any mental status changes and the circumstance of the depression 8. With diabetes may alter glucose levels and the dosage of diabetic medications may need changed. Report early symptoms of ophthalmic pathology, such as headache, dizziness, blurred vision, or partial loss of vision, and get a thorough eye pain. Stimulant laxatives: substances that chemically stimulate the smooth muscles of the bowel to increase contractions, (Bisacodyl, Cascara, Danthron, and Senna). Saline laxatives – substances that increase the bulk of the stools by retaining water, (Magnesium Salts and Sodium Phosphate) Bulk forming laxatives – non digestible substances that pass through the stomach and then increase the bulk in the stools (Methylcellulose and Psyllium). Emollient and lubricant laxatives – agents that soften hardened feces and facilitate their passage through the lower intestine (Docusate and Mineral Oil). Uses – See individualized drugs, short term treatment of constipation, prophylaxis in patients who should not strain during defecation (following ano rectal surgery, or after heart attack use fecal softeners or lubricant laxatives), to evacuate the colon for rectal and bowel examinations (certain lubricant, saline, and stimulant laxatives). In conjunction with surgery or anthelminitic therapy, the underlying cause of constipation should be determined since a marked change in bowel habits may be a symptom of a pathological condition. Contraindication: Severe abdominal pain that might be caused by appendicitis, enteritis, ulcerative colitis, diverticulitis, intestinal obstruction, laxatives used in these conditions may cause rupture of the abdomen or intestinal hemorrhage, undiagnosed abdominal pain in children under the age of 2 can also be a contraindication. If ordered to prepare for a diagnostic test, check directions carefully to ensure accurate administration. Determine length of use and underlying causes, note type taking and effectiveness. With abdominal pain and discomfort, note location and type of discomfort experiencing. Determine stool characteristics and frequency, patient definition if in fact constipation exists. Identify any special restrictions or limitation due to illness, may include sodium/fluid restriction. List other drugs that may contribute to constipation (diuretics, anticholinergics, antihistamines, antidepressants, narcotic analgesics, iron products, and some hypertensive agents, especially Verapamil). Have a regular schedule for defecation, keep record of bowel function and response to all laxatives taken. Laxatives reduce the amount of time other drugs remain in the intestine and may diminish effectiveness. If taken as a prep for a diagnostic test, review instructions, if unable to read, find someone to review directions, to ensure an accurate test. Review techniques that facilitate elimination, sitting with legs slightly elevated and leaning forward to increase abdominal pressure often encouraging elimination; if ill at home, consider a commode at the bedside, this will promote better bowel function by encouraging patient to move about and ensure privacy. Bowel tone will be lost with longterm use of laxatives, bowel movements do not have to occur daily, use diet to achieve same purpose, two or three prunes a day are preferable to laxatives. Frequent use of any type of enemas may cause damage to the rectum, and small bowel as well as inhibit bowel tone and may also cause electrolyte abnormalities. Review importance of diet high in fiber foods (add juices, such as prune), daily exercise and benefits in maintaining proper bowel function, include bulk foods and sufficient fluids to diet to enhance elimination, consult dietician for assistance in meal planning/preparation and food selection. Report if constipation persists because there could be a physiological problem that requires attention. Stimulant laxative that increases peristalsis, probably by direct effect on smooth muscle of the intestine, by irritating the muscle or stimulating the colonic intramural plexus. Up to 30 mg as needed or 10 mg per rectum for evacuation before examination or surgery for adults and children age 12 and older. Orally the onset of action is within 6 – 12 hours and the peak and duration is variable.

Which of the following is an unusual complication Answers to Questions 1–5 that may occur in infectious mononucleosis? Which of the following is contained in the primary 1-year-old child is 61% compared to the mean granules of the neutrophil? What is the typical range of relative lymphocyte percentage in the peripheral blood smear of a 1-year-old child? Qualitative and quantitative neutrophil changes Answers to Questions 6–10 noted in response to infection include all of the following except: 6 discount digoxin 0.25mg. A Neutropenia is defined as an absolute decrease in the absolute neutrophil counts? B Chédiak–Higashi syndrome is a disorder of Hematology/Evaluate laboratory data to recognize neutrophil phagocytic dysfunction caused by health and disease states/Differential normal values/2 depressed chemotaxis and delayed degranulation buy digoxin 0.25mg visa. Te morphological characteristic(s) associated interference from the giant lysosomal granules with the Chédiak–Higashi syndrome is (are): characteristic of this disorder. Small, dark-staining granules and condensed reported in 1 out of 6,000 individuals. Nuclear hyposegmentation numerous band neutrophils and metamyelocytes that may be observed during severe infection or a Hematology/Recognize morphological changes shift-to-the-left of immaturity in granulocyte stages. A shift-to-the-left increase in immature common cause of heterophile-negative infectious granulocytes mononucleosis. Neutrophil phagocytosis and particle ingestion are Answers to Questions 11–12 associated with an increase in oxygen utilization called respiratory burst. A The biochemical products of the respiratory burst important products of this biochemical reaction? Hydrogen peroxide and superoxide anion during phagocytosis are hydrogen peroxide and B. Alkaline phosphatase and ascorbic acid phagolysosome, where it converts O2 to superoxide – anion (O2 ), which is then reduced to hydrogen Hematology/Apply knowledge of fundamental peroxide (H2O2). Which of the morphological findings are basophilic cytoplasm, a high N:C ratio, and the characteristic of reactive lymphocytes? High nuclear:cytoplasmic ratio have an extremely fine nuclear chromatin staining B. C Acute leukemia is usually associated with a Hematology/Apply knowledge of fundamental normocytic normochromic anemia. Anemia in biological characteristics/Acute leukemia/1 acute leukemia is usually present from the onset and may be severe; however, there is no inherent 2. Which type of anemia is usually present in a nutritional deficiency leading to either a microcytic, patient with acute leukemia? Normocytic, normochromic red cells is called leukoerythroblastosis and frequently D. In leukemia, which term describes a peripheral blood finding of leukocytosis with a shift to the 4. D A normal physiological response to anemia would left, accompanied by nucleated red cells? Te basic pathophysiological mechanisms responsible for producing signs and symptoms in leukemia include all of the following except: A. Decreased erythropoietin production Hematology/Correlate clinical and laboratory data/ Leukemia/2 21 22 Chapter 1 | Hematology 5. Which type of acute myeloid leukemia is called Answers to Questions 5–9 the true monocytic leukemia and follows an acute or subacute course characterized by monoblasts, 5. Acute myeloid leukemia, minimally differentiated distinctive clinical manifestation of monocytic B. Acute myeloid leukemia without maturation involvement resulting in skin and gum hyperplasia. B A disproportionate increase in the myeloid most often associated with which of the following component of the bone marrow is usually the types of acute leukemia? Acute myeloid leukemia without maturation approximately 4:1 in adults with normal cellularity. Acute monocytic leukemia cytoplasm of myeloblasts and monoblasts in Hematology/Evaluate laboratory data to recognize patients with acute leukemia. Myelofibrosis Hematology/Evaluate laboratory data to recognize health and disease states/Bone marrow/M:E/2 9. Tey are nonspecific esterase positive Hematology/Apply knowledge of fundamental biological characteristics/Leukocytes/Auer rods/1 1. Acute myelomonocytic leukemia Leukocytes/Cytochemical stains/2 Hematology/Evaluate laboratory data to make identifications/Leukemia/3 Answers to Questions 10–14 11. C In acute erythroid leukemia, more than 50% of with a fever, pallor, lymphadenopathy, and nucleated bone marrow cells are erythroid and more hepatosplenomegaly. Tese stain positive for both Sudan Black B are characteristically negative with these stains. C Phospholipids, neutral fats, and sterols are stained by of the following disorders is most likely? The addition of fluoride renders the monocytic cells (and blasts) negative, thus allowing for differentiation from the granulocytic cells, which remain positive.