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Post-operative care must be approached in an organized buy ketoconazole 200mg without a prescription, timely manner generic ketoconazole 200mg with amex, with attention to the acute nature of the patient’s changing physiology cheap 200mg ketoconazole with visa. Before the patient arrives ketoconazole 200mg low cost, you should familiarize yourself with the patient’s past medical/surgical history and the planned surgical procedure buy ketoconazole 200 mg overnight delivery. Only when you know what they planned to do, and what they did it on, will you be prepared to evaluate your patient when he/she arrives, and anticipate potential problems that you must watch for. When the patient arrives--the initial evaluation The patient has just undergone general anesthesia, been intubated +/- extubated, and had some fairly invasive procedure performed. The anesthetic record can be viewed as the “history of present illness” for the surgical patients--it contains information related to maintaining physiologic stability during the course of the operation. Each hospital’s record is somewhat different, but all will contain the following information: 1. Maintenance of anesthesia--potent inhalational agents (halothane/isoflurane/sevoflurane), nitrous oxide, narcotics, propofol. Lines and tubes Fluids in the Operative and Post-operative patient Pediatrician: “Why do they always get so much fluid? Major abdominal procedures can lead to losses of 15 cc/kg/hr in “third space” losses which must be replaced. Effect of Anesthesia on Fluid Balance: General anesthesia produces vasodilatation and some degree of myocardial contractility (usually overcome by sympathetic drive induced by the surgical stimulus), and thus a volume bolus may be needed. There is much discussion about which is better, what the cost/benefit ratio is, etc. You should at least be aware of which is which, and of the implications of choosing one over the other. Water flows along its concentration gradient, hence, water will leave the vascular space with the sodium, and less so with albumin. There is controversy (in the literature and with respect to individual patients) regarding when one needs to transfuse the patient. Remember that the function of red cells is to carry hemoglobin, carried by cardiac output. O2 transport capacity will thus be a factor of Hg level and the ability of the Hg to get to cells--which will be adversely affected by hyper viscosity. This does not, however address the issue of “tolerable” hematocrit--healthy patients will tolerate much lower hematocrits, and there is a risk involved in any transfusion. Component Therapy During a massive transfusion, coagulation factors and platelets will be reduced due to dilution, as they are not present in packed cells. If not replaced, bleeding will be greater, necessitating greater packed cell transfusion, etc. Extubation Criteria for extubation in the operating room are the same as those elsewhere--the patient must have an adequate airway, maintain oxygenation and ventilation (adequate strength as well as lung function), and have a neurologic status able to protect the airway and maintain adequate drive. Did the operation affect the airway (trachea, cords, pharynx) Breathing--Are the lungs normal or abnormal. Has there been enough fluid administered that there is concern about pulmonary edema? Did the operation involve the chest or abdomen in a way that will adversely affect the patient’s ability to breathe deeply? Neuro--Has anesthesia worn off to a degree that the patient can protect his airway and have adequate drive. Stridor--causes include trauma to trachea or cords, laryngeal edema, recurrent nerve damage, arytenoid dislocation. Treatment is as for viral croup--racemic epi, decadron, and re-intubation if necessary. If patient’s airway is compromised due to decreased mental status, a jaw thrust and nasal airway may temporize the problem. Generally patients will require some oxygen due to atelectasis, narcotics, and splinting. Remember that the In/Outs will not necessarily reflect the patient’s intravascular volume status (due to blood loss replacement, third space losses, evaporative losses). Of note, hypercarbia will lead to sympathetic nervous system activation, with impressive hypertension and tachycardia. Titration of drugs in the infant or ventilated/sedated/paralyzed patient requires assessment of vital signs. Common Procedures and Common Problems Spinal Fusion--Respiratory, Pain, Fluid Balance The post-operative course will be affected by the patient’s general medical history, degree of curvature, extent of the repair, and intraoperative course (fluid balance, blood loss, narcotics given). The most dreaded complication is paralysis, and patients who are cognitively able to follow commands will be submitted to a “wake-up test” intra-operatively, before closure of the wound. Potential post op problems include respiratory depression (excess analgesia), respiratory difficulty due to splinting (inadequate analgesia), pain control (difficult), and fluid balance. There is typically a fair bit of blood loss and there can be significant swelling of the involved tissues.

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An accurate and prompt diagnosis will not only help to control the spread of infection order ketoconazole 200mg amex, it will also minimize the inappropriate use of antibiotics ketoconazole 200 mg line. The inappro- priate use of antibiotics is a consideration because most cases of pharyngitis are caused by viruses cheap ketoconazole 200 mg with visa, and of the many bacterial patho- gens that cause pharyngitis (Table 10 generic ketoconazole 200 mg with visa. Indeed discount 200mg ketoconazole free shipping, cases of group A streptococcal pharingytis represent only 20% of all pharyngitis cases (9). The complex of symptoms include a sudden onset of high fever, very sore throat with dysphagia, a scarlatiniform rash and abdominal pain. Numerous at- tempts have been made to devise algorithms to make the clinical diagnosis easier (especially in areas where a microbiology laboratory is not available), but in general these algorithms lack accuracy and are not universally helpful. Examples of the most frequently observed clinical findings, signs and symptoms are shown for different age groups in Table 10. No single element of history taking or physical examination is accu- rate enough to exclude or diagnose streptococcal throat infection. Patient factors such as age younger than 15 years, history of fever, tonsillar swelling or exudate, tender anterior cervical lymphadenopa- thy and absence of cough should all be taken into consideration in arriving at a diagnosis. If four or five of the factors are present, the likelihood ratio of streptococcal infection is 4. Laboratory diagnosis Since the clinical diagnosis of acute streptococcal pharyngitis is often imprecise, laboratory confirmation is needed, although in many parts of the world clinical laboratory facilities are not available (7, 8, 11, 12). If carried out properly, the sensitivity and specificity of this assay 83 Table 10. Rapid antigen detection tests are available in some parts of the world, and almost exclusively use antibodies directed against the group A carbo- hydrate of the streptococcal cell wall. In general, they are more expensive than blood agar plates, and like culture plates they need refrigeration, which can be a problem in some parts of the world, especially those with tropical climates. If laboratory facilities are not available, a diagnosis of strepto- coccal pharyngitis has to be made on the basis of clinical findings (7, 8, 11–13). To date, no clinical isolate of group A beta-hemolytic streptococcus (Streptococcus pyogenes) has been shown to be resistant to penicillin. To eradicate a group A strep- tococcal infection, oral penicillin (penicillin V or penicillin G) should be given for a full 10 days (25–29). A single intramuscular injection of benzathine benzylpenicillin can be used to treat the infection if it is anticipated that the patient will not adhere to a treatment regimen of oral antibiotics. For patients with allergies to penicillin, the macrolide erythromycin has been the recommended antibiotic of choice for many years. How- ever, in the 1960s and 1970s, the prevalence of macrolide-resistant group A streptococci began to increase in areas where macrolides were widely used, to the point that it became a clinically significant problem (e. In many coun- tries, resistance to macrolide antibiotics has reached more than 15%. In some cases, the increase in resistance has been related to the introduction of new macrolide drugs that frequently are recommended only for abbrevi- ated therapy. M-typing of strains when possible may be necessary to establish whether the recurrence was because of treatment failure or because of a new infection. The same antibiotic used to treat the infection initially should be administered, especially if a new infection is suspected. If oral penicillin had been used ini- tially, then a single intramuscular injection is recommended. If it is suspected that the streptococci are penicillinase producers it is advis- able to administer clindamycin or amoxycillin/clavulanate (9, 26, 34–36). Other primary prevention approaches Although a cost-effective vaccine for group A streptococci would be the ideal solution, scientific problems have prevented the de- velopment of such a vaccine (see Chapter 13, Prospects for a strepto- coccal vaccine). Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amount of depot penicillin. The virtual disappearance of rheumatic fever in the United States: lessons in the rise and fall of disease. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clinical use and interpretation of group A streptococcal antibody tests: a practical approach for the pediatrician or primary care physician. A controlled study of penicillin therapy of group A streptococcal acquisitions in Egyptian families. A review of the rationale and advantages of various mixtures of benzathine penicillin G. A comparison of four treatment schedules with intramuscular penicillin G benzathine.

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The inferior oblique muscle originates from the floor of the orbit and inserts into the inferolateral surface of the eye cheap 200mg ketoconazole visa. Rotation of the eye by the two oblique muscles is necessary because the eye is not perfectly aligned on the sagittal plane trusted 200mg ketoconazole. When the eye looks up or down ketoconazole 200mg lowest price, the eye must also rotate slightly to compensate for the superior rectus pulling at approximately a 20-degree angle cheap 200 mg ketoconazole mastercard, rather than straight up discount 200 mg ketoconazole. The same is true for the inferior rectus, which is compensated by contraction of the inferior oblique. A seventh muscle in the orbit is the levator palpebrae superioris, which is responsible for elevating and retracting the upper eyelid, a movement that usually occurs in concert with elevation of the eye by the superior rectus (see Figure 14. All of the other muscles are innervated by the oculomotor nerve, as is the levator palpebrae superioris. The sclera accounts for five sixths of the surface of the eye, most of which is not visible, though humans are unique compared with many other species in having so much of the “white of the eye” visible (Figure 14. The middle layer of the eye is the vascular tunic, which is mostly composed of the choroid, ciliary body, and iris. The choroid is a layer of highly vascularized connective tissue that provides a blood supply to the eyeball. The choroid is posterior to the ciliary body, a muscular structure that is attached to the lens by suspensory ligaments, or zonule fibers. Overlaying the ciliary body, and visible in the anterior eye, is the iris—the colored part of the eye. The iris is a smooth muscle that opens or closes the pupil, which is the hole at the center of the eye that allows light to enter. The iris constricts the pupil in response to bright light and dilates the pupil in response to dim light. The innermost layer of the eye is the neural tunic, or retina, which contains the nervous tissue responsible for photoreception. The posterior cavity is the space behind the lens that extends to the posterior side of the interior eyeball, where the retina is located. The retina is composed of several layers and contains specialized cells for the initial processing of visual stimuli. The change in membrane potential alters the amount of neurotransmitter that the photoreceptor cells release onto bipolar cells in the outer synaptic layer. Because these axons pass through the retina, there are no photoreceptors at the very back of the eye, where the optic nerve begins. A significant amount of light is absorbed by these structures before the light reaches the photoreceptor cells. At the fovea, the retina lacks the supporting cells and blood vessels, and only contains photoreceptors. This is because the fovea is where the least amount of incoming light is absorbed by other retinal structures (see Figure 14. As one moves in either direction from this central point of the retina, visual acuity drops significantly. The difference in visual acuity between the fovea and peripheral retina is easily evidenced by looking directly at a word in the middle of this paragraph. The visual stimulus in the middle of the field of view falls on the fovea and is in the sharpest focus. Without moving your eyes off that word, notice that words at the beginning or end of the paragraph are not in focus. The images in your peripheral vision are focused by the peripheral retina, and have vague, blurry edges and words that are not as clearly identified. As a result, a large part of the neural function of the eyes is concerned with moving the eyes and head so that important visual stimuli are centered on the fovea. The inner segment contains the nucleus and other common organelles of a cell, whereas the outer segment is a specialized region in which photoreception takes place. There are two types of photoreceptors—rods and cones—which differ in the shape of their outer segment. The rod-shaped outer segments of the rod photoreceptor contain a stack of membrane-bound discs that contain the photosensitive pigment rhodopsin. The cone-shaped outer segments of the cone photoreceptor contain their photosensitive pigments in infoldings of the cell membrane. There are three cone photopigments, called opsins, which are each sensitive to a particular wavelength of light. The pigments in human eyes are specialized in perceiving three different primary colors: red, green, and blue. Rod outer segments are long columnar shapes with stacks of membrane-bound discs that contain the rhodopsin pigment. Cone outer segments are short, tapered shapes with folds of membrane in place of the discs in the rods. A single unit of light is called a photon, which is described in physics as a packet of energy with properties of both a particle and a wave.

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Metabolic actions: (a) Thermogenic action (b) Competes with aldosterone at renal tubule so inhibits sodium reabsorption generic ketoconazole 200 mg online. They can also be classified as fixed dose combination (monophasic) ketoconazole 200 mg with visa, biphasic and triphasic pills buy 200mg ketoconazole otc. Fixed dose combination: the commonest procedure is to administer one pill containing both an estrogen and progestin daily at bed time for 21 days buy generic ketoconazole 200 mg line. In biphasic and triphasic pills: these are combined oral contraceptive pills containing varying proportion of an estrogen and a progesterone designed to stimulate the normal pattern of menustral cycle generic 200mg ketoconazole with amex. Medroxyprogestrone acetate (Depoprovera ) iii) Subcutanous implant L – norgestril (Norplant®) Mechanism: It makes cervical mucus thick, though & hostile and also alter endometrial wall B. Post coital “morning after” pill Oestrogen like Diethyl stilbosterol used within 72 hrs Combined oral contraceptive pills can also be used. Side effects of oral contraceptive: Thromboembolic complication, Weight gain & fluid retention, Menstrual disorder, Breast tenderness & fullness, Skin changes, Nausea & vomiting, Depressed mood, Reduced lactation Beneficial effects of estrogen /progesterone oral contraceptive 1) Reduced risk of endometrial Carcinoma, ovarian cyst 2) regular Menses, No excessive blood loss 3) Less premenustrual tension and dysmennorrhea 4) Relief of endometriosis Contraindication: In patients withcardiovascular diseases (hypertension, coronary heart disease) Thromboemolic disease, breast Cancer, diabetes mellitus, liver disease, women > 35 years (esp. Effect reduced when taken with enzyme inducers like Rifampicin, Phenytoin, Phenobarbitone etc. Oral contraceptive antagonize the effect of Coumarin anticoagulant and some antihypertensives Ovulation inducing drug These are drugs used in the treatment of infertility due to ovulatory failure. Therapeutic activity in inflammatory disorder is proportional to the glucocorticoid activity. They are not widely used in therapeutics rather its antagonists are of value in cases of edema. Thyroid and Antithyroid Drugs They inhibit the function of the thyroid gland and used in hyperthyroidism. Radioactive iodine ( I) Thiourea Compounds Inhibit the formation of throid hormone through inhibiting the oxidation of iodide to iodine by peroxidase enzyme and blocking the coupling of iodothryosines to form iodothyronines. Toxicities include drug fever, skin rashes, increased size and vascularity of the thyroid gland, and agranulocytosis. Ionic Inhibitors Potassium percholate prevents the synthesis of thyroid hormones through inhibition of uptake and concentration of iodide by the gland. It has the risk of aplastic anemia, therefore no longer used in the treatment of hyperthyroidism. Iodides: Improve manifestations of hyperthyroidism by decreasing the size and vascularity of the gland so they are required for preoperative preparation of the patient for partial thyroidectomy. Iodides act through inhibition of the “protease” enzyme which releases T3 and T4 from thyroglobulin, and organification. It is trapped and concentrated as ordinary iodine, which emits beta rays that act on parenchymal cells of the gland. It is contraindicated in pregnancy and lactation as it affects thyroid gland in the fetus and the infant. Propranolol This is an important drug which controls the peripheral manifestations of hyperthyroidism (tachycardia, tremor). Manifestations include hyperpyrexia, gastrointestinal symptoms, dehydration, tachycardia, arrhythmia, restlessness, etc. Management: It consists of infusion of intravenous fluids, supportive management, and also administration of propylthiouracil, sodium iodide, hydrocortisone, and propranolol. Discuss the mechanism and beneficial effects of combined oral contraceptive pills. Describe the mechanims of action and the adverse effects of antituberculois drugs. Discuss the use, mechanism of action and problems associated with anthelminthic drugs. Antimicrrobials: are chemical agents (synthetic/natural) used to treat bacterial, fungal and viral infections. Antibiotics: are substances produced by various species of microorganisms (bacteria, fungi, actinomycetes) that suppress the growth of other microorganisms. Bactericidal versus bacteriostatic action: When antimicrobial agents lead to the death of the susceptible microbe (e. Antiprotozoals: are drugs used to treat malaria, amoebiasis, gardiasis, trichomoniasis, toxoplasmosis, pneumocystis carinii pneumonia, trypanosomiasis and leshmaniasis. The classificastion, pharmacokinetics, pharmacodynamics, clinical uses, adverse effects of commonly used antimicrobias, antiprotozoals, antihelimenthics are disscused. Alteration of the drug-binding site: this occurs with penicillins, aminoglycosides and erythromycin. Anibacterial agents Cell wall synthesis inhibitors Members the group: Beta-lactam antibiotics, vancomycin, bacitracine, and cycloserine Beta-lactam antibiotics: Penicillins, cephalosporins, carbapenems, and monobactams are members of the family. All members of the family have a beta-lactam ring and a carboxyl group resulting in similarities in the pharmacokinetics and mechanism of action of the group members. They are water-soluble, elimination is primary renal and organic anion transport system is used. Penicillins Penicillins have similar structure, pharmacological and toxicological properties.

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Although clearly an 104 Hematology obsolete method (because the combined error of dilution and enumeration is high) cheap ketoconazole 200 mg on line, visual counting will still has to be undertaken for some years to come in the smaller laboratories buy 200mg ketoconazole amex. Principle A sample of blood is diluted with a diluent that maintains (preserves) the disc-like shape of the red cells and prevents agglutination and the cells are counted in a Neubauer or Burker counting chamber cheap ketoconazole 200mg with visa. Diluting Fluid 1% formal citrate Dilution Thomma Red Cell Pipette Take a well mixed blood or blood from a freely flowing capillary puncture to the “0 cheap ketoconazole 200 mg on-line. Tube Dilution Take 20µl blood with sahli pipette and mix it with 4ml diluent in a small tube to give a final dilution of 1:201 105 Hematology Counting and Calculation After the suspension is charged into the chamber and the cells allowed to settle generic 200mg ketoconazole amex, cells should be counted using the 40× objective and 10× eyepiece in 5 small squares of the central 1mm2 area of the improved Neubauer counting chamber (4 corner and 1 central squares each with an area of 0. It is important to count as many cells as possible for the accuracy of the count is increased thereby; 500 cells should be considered as the absolute minimum. Platelet counts are also performed when patients are being treated with cytotoxic drugs or other drugs which may cause thrombocytopenia. Method using formal-citrate red cell diluent Diluent should be prepared using thoroughly clean glassware and fresh distilled water. To prevent drying of the fluid, place the chamber in a petri dish or plastic container on dampened tissue or blotting paper and cover with a lid. Count the number of platelets which will appear as small refractile bodies in the central 1mm2 area with the condenser racked down. Not more than 500ml should be prepared at a time using thoroughly clean glassware and fresh distilled water. The preparation is mixed, the chamber filled and the cells allowed to settle in a similar fashion as Method 1. The cells are counted in 5 small squares in the central 1mm2 of the improved Neubauer counting chamber. Rough estimation of platelet number from a stained blood film Normally there are 10-20 platelets per oil immersion field. Special care must be taken when counting platelets: • To check there are not clots in the blood sample. Platelet counts from capillary blood are usually 111 Hematology lower than from venous blood and are not as reproducible. Thrombocytosis Causes of an increase in platelet numbers include: • Chronic myeloproliferative disease e. Principle Blood is diluted with a fluid that causes lysis of erythrocytes and stains eosinophils rendering them readily visible. Diluting Fluid Hinkleman’s fluid It has the advantage of keeping well at room temperature and not needing filtering before use. Method Make dilution of blood using thomma pipette or tube dilution as described for the white cell count. Reference range 40 - 440 × 106/l Interpretation of eosinophil counts Eosinophilia is common in allergic conditions (e. How do you calculate the number of cells per unit volume of blood after you count the cells in a sample of diluted blood? The count is usually performed by visual examination of blood films which are prepared on slides by the wedge technique. For a reliable differential 117 Hematology count the film must not be too thin and the tail of the film should be smooth. This should result in a film in which there is some overlap of the red cells diminishing to separation near the tail and in which the white cells on the body of the film are not too badly shrunken. If the film is too thin or if a rough-edged spreader is used, 50% of the white cells accumulate at the edges and in the tail and gross qualitative irregularity in distribution will be the rule. The polymorphonuclear leucocytes and monocytes predominate at the edges while much of smaller lymphocytes are found in the middle. The problem is to overcome the differences in distribution of the various classes of cells which are probably always present to a small extent even in well made films. Of the three methods indicated underneath for doing the differential count, the lateral strip method appears to be the method of choice because it averages out almost all of the disadvantages of the two other methods. The Longitudinal Strip Method The cells are counted using the X40 dry or X100 oil immersion objectives in a strip running the whole length of the film until 100 cells are counted. If all the cells are counted in such a strip, the differential totals will approximate closely to the true differential count. The Exaggerated Battlement Method In this method, one begins at one edge of the film and counts all cells, advancing inward to one-third the width of the film, then on a line parallel to the edge, then out to the edge, then along the edge for an equal distance before turning inward again. For example: • Erythrocytes: size, shape, degree of hemoglobinization; presence of inclusion bodies, presence of nucleated red cells (if so, the total leucocyte count must be corrected. The fact that a patient may have 60% polymorphs is of little use itself; he may have 60% of a total leucocyte count of 8. Band (stab) cells are generally counted as neutrophils but it may be useful to record them separately. An increase may point to an inflammatory process even in the absence of an absolute 122 Hematology leucocytosis.