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By: Bertram G. Katzung MD, PhD

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Loss of the contents of the small intestine can purchase symbicort 5mcg line asthma treatment alternatives, less commonly discount 5mcg symbicort with amex asthma symptoms of bronchitis, result in metabolic acidosis discount symbicort 5mcg without prescription asthma treatment in hyderabad. Causes of nausea and vomiting are multiple cheap 5mcg symbicort free shipping asthma organizations, and a careful history and physical assessment are needed to make a determination. It may be bright red or look like coffee grounds if it has been broken down by the digestive process. They have many of the same side effects: dry mouth, hypotension, sedative effects, constipation. Constipation�Interval between bowel movements is longer than usual for the patient and the stool is hard and dry 1. History (1) Patient�s diet lacks sufficient fiber, and fluid intake is inadequate (2) Patient immobility (3) Disease of the colon or rectum is present (4) Medication is taken with side effect of constipation b. Clinical findings (1) Abdominal distention (2) Decreased amount of stool (3) Dry, hard stool 2. Prevent accumulation of stool in the colon�ask client not to ignore urge to defecate. Diarrhea�significant increase in number of stools and stools are watery or loosely formed 1. Evaluate possible causes including intestinal infections, food poisoning, malabsorption problems, psychological factors b. Stools are frequent and loose and may contain undigested food, mucus, pus, or blood c. Dehydration, hypovolemia, hypokalemia, and shock possible� especially in infants and the elderly 2. Oral Cancer�may occur anywhere in the mouth (lips, tongue, salivary glands, pharynx, tonsils), often curable if discovered early. Postoperative priorities include maintaining patent airway, promoting drainage, evaluating ability of patient to handle secretions, and positioning appropriately c. Maintain nutrient intake by tube or parental feedings if necessary, or with bland and soft foods g. Provide discharge planning by helping identify rehabilitation needs such as speech therapy h. Teach client symptoms of complications and to notify provider of infection, increased pain, difficulty swallowing, or suture line bleeding E. Assist patient to modify diet to decrease highly seasoned foods, fatty foods and caffeine, which all can cause discomfort, and to have small frequent meals c. Gastric ulcers�food may cause the pain, vomiting may relieve it; duodenal ulcers, pain with an empty stomach, relieved by eating c. Signs of perforation: hypotension (blood presssure decrease of 10 mm Hg or more), sudden severe upper abdominal pain, rigid abdomen, absent bowel sounds, shallow, rapid respirations 3. Dietary modification�often highly individual, foods that cause pain are avoided c. Medications�antacids, H2 receptor antagonists, acid pump inhibitors, prokinetics, anticholinergics 4. Dumping Syndrome�a post-gastric surgery condition in which the intestine is unable to handle a large amount of food that has been adequately mixed with gastric secretions 1. Weakness, dizziness, tachycardia, diaphoresis after meal; followed by epigastric fullness, abdominal cramping, and diarrhea. Self-limiting Drug Treatment for Peptic Ulcer Drug Classification Generic and Trade Names Nursing Considerations Antacids Magnesium and aluminum hydroxide (Maalox) Administer after meals. Dicyclomine (Bentyl) Monitor for drowsiness, urinary retention, constipation Histamine2 Receptor Cimetidine (Tagamet) Take 1 hour before meals. Antagonists Ranitidine (Zantac) Monitor blood count, kidney, Famotidine (Pepcid) and liver function Prostaglandin Misoprostol (Cytotec) Do not give during pregnancy. Gastric Cancer�Symptoms are often not apparent until the disease has metastasized into adjacent organs. More common in men, Asians; associated with highly salted or smoked foods, peptic ulcer, low intake of vegetables and fruits, chronic gastritis 1. Do: place in position of comfort on bed rest, assess hydration, abdominal distention, bowel sounds, pain, passage of flatus or stool. Assess drainage, monitor abdomen for distention and assess peristaltic activity. Intestinal Obstruction�complete or partial blockage of the small or large intestine; can be due to mechanical problems such as tumors, neurological difficulties such as paralytic ileus; increased pressure above blockage and decreased peristalsis below; higher the obstruction, the more severe the symptoms. Small intestine obstruction (1) Vomiting�possibly fecal (2) Abdominal distention (3) Absence of stools (4) Dehydration b. Large bowel obstruction�slower progression of symptoms (1) Constipation (2) Abdominal distention (3) Cramplike pain in lower abdomen 2. Record intake and output, including amount and character of drainage from decompression tube c. Diverticular Disease (Diverticulosis/Diverticulitis)�Diverticulosis is an outpouching of the mucosa of the colon; diverticulitis is an inflammation of the outpouching (diverticulum). Drug treatment�bulk laxatives, antibiotics, stool softeners, and anticholinergics c. Teach patient about dietary restrictions, avoidance of constipation, and activity that increases intra-abdominal pressure L. Hernias�protrusion of an organ (usually refers to the intestines) through an abnormal opening 1.

Follow steps above symbicort 5mcg cheap asthma treatment guidelines for adults, except sterile saline is used to symbicort 5mcg on-line asthma definition untenable moisten dressing; acts to generic 5 mcg symbicort free shipping new asthma treatment 2013 help clean wound and remove necrotic tissue symbicort 5mcg with visa asthma symptoms 0f. Don�t get the dressing too wet; it should be allowed to dry between dressing changes. Obtaining A Wound Culture�must be done before antibiotics are given or antimicrobial agent is applied to wound a. Dressing Changes�usually the first; dressings over catheters which go into body cavities 5. Sterile field must be within your view (don�t turn your back on a sterile field) 2. Moisture will carry bacteria through a cloth barrier, so wet areas are not sterile. Peel the outer flaps of sterile supplies apart like a banana, and drop the inner sterile package onto the sterile field. Do not touch the inside of the sterile packaging, and don�t allow the unsterile container to contaminate the sterile field by holding it at least 6 inches above it. Wash hands and open outer wrap of the sterile glove package and remove the inner wrap 2. Once open, use your dominant hand to grasp the opposite glove on the inner fold of the cuff, and carefully slip your nondominant hand into it 5. With your sterile gloved hand, slip your fingers under the folded cuff of the remaining glove 7. Can also withdraw urine from a Foley catheter through the access port with a sterile needle after wiping the port with alcohol 2. Collect midstream specimen by having patient start to void, stop, then void into a sterile container c. Identifies organisms causing an infection as well as drugs that may be used to treat it 2. Allow family time alone with the patient after completing the preparations above 5. Surgical asepsis is needed for administering an intramuscular injection because it involves intentional perforation of a client�s skin. Procedures requiring surgical asepsis include those involving broken skin or which involve insertion of catheters or surgical instruments into sterile body cavities. When putting on the first glove, the aide indicates that she is following correct technique by grasping it (1) at the top edge of the cuff. When putting on sterile gloves, the first glove is grasped by the folded edge of the cuff with the nondominant hand. The second glove is then picked up by slipping the fingers of the gloved hand under the cuff and inserting the nondominant hand. She cannot decide whether or not a test is appropriate; that is the provider�s responsibility. After gathering all of the necessary equipment, the nurse begins to open the sterile pack containing the catheter set. Which of these steps should be taken first when implementing this aseptic procedure The sterile gloves (1) should be put on after the pack is opened since the outside is unsterile. Opening the outermost flap of the pack first (4) prevents contamination of the sterile field by reaching over it to open it after the front or sides have been opened (2) and (3). She opens a sterile drape and places it over the top and sides of the table, and carefully peels back the wrapping of several syringes and drops them on the table. The nurse, who is wearing a sterile gown and gloves, realizes that she may only touch one of the following in order to maintain sterility: (1) the water in the bowl (2) the border of the sterile drape (3) the spot where the water splashed (4) the part of the drape covering the sides of the table Rationale: the correct answer is (1). The water in the bowl is sterile, but the one inch border of the drape (2), the spot where the water splashed (3) and the sides of the table (4) are all considered unsterile according to current practice guidelines. The nurse documents the characteristics of wound drainage after she changes the dressing. When changing a dressing, the nurse should chart the color, amount, and odor of any discharge present. Gastric tube feeding, however, merely requires clean technique, or medical asepsis. Ann Taylor has just been transferred to her postpartum room after delivering a stillborn infant. Part of the grieving process involves confirmation and validation of the parents� feeling of loss, and it is helpful for the parents to hold the baby and spend time alone with him or her to do this. The woman�s daughter tells the nurse that they do not want her told that she is dying because she �would not be able to handle it. Denial of an older person�s impending death makes it impossible for the dying person to talk about what is happening to her and for the family to fully take advantage of their last opportunity to communicate. The best way to obtain the specimen is to: (1) open the port on the holding bag and obtain approximately 100cc to use for both tests. Only by entering the port with a sterile needle will a sterile specimen be obtained. Methods were determined for regulating the manufacture, distribution, and sale of controlled substances. Schedule I�Drugs that have a high potential for abuse and are not approved for medical use in the U. Schedule V�Drugs with the lowest potential for abuse, which may be dispensed by the pharmacist without a prescription, but which should have some restrictions, such as record-keeping. Drugs have one or more desired actions for which they are administered and also responses 1. May have unexpected responses, such as an allergic reaction or idiosyncratic response by an individual B.

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Lesions of the motor side of the reflex arc Ill sustained clonus < 6 downward beats of the a symbicort 5 mcg fast delivery asthma uncommon symptoms. Any weakness detected is noted and analysed by comparing with the power of the similar group of muscles on the normal side order 5 mcg symbicort asthma symptoms checker. Note is made as to cheap symbicort 5 mcg amex asthma symptoms in 7 month old the predominant groups of muscles involved (proximal order symbicort 5mcg without prescription asthma definition xenophobe, distal or both proximal and distal). The causes of predominant proximal muscle weakness, predominant distal muscle weakness or both proximal and distal muscle weakness are the same as listed for muscle wasting. The quantitative assessment of power can be done by grading the muscle power as suggested by the Medical Research Council. Sustained clonus and at times even the ill-sustained Grade 3 Movement against gravity. Grade 2 Gravity eliminated movement (lateral the muscles must be palpated and percussed to movements in bed). This is a Normally, the larger the muscle group, the greater is feature of myotonia. The power of the muscles of mastication (small this is a state in which muscle contraction continues muscles) is greater than the power of the pectoral beyond the period of time required for a particular muscles (large muscles). The power in muscular dystrophies is weak, in spite It is best seen in the face and hand muscles. Some amount of muscle power is retained inspite of his facial muscle, a delay in relaxation of the muscle is the muscle wasting seen in motor neuron disease. Coordination Similarly when the patient is asked to grip the examiner�s fingers and then let go immediately, a delay Coordination of the limbs can be tested effectively only in the relaxation of the grip is noted. It is always better to explain the procedure properly Conditions Causing Myotonia to the patient so that the patient can perform the act smoothly. Paramyotonia congenita (myotonia occurs on All tests for coordination are done initially with eyes exposure to cold). Power Coordinated action of the muscles is under cerebellar Muscle power is the force of contraction that can be control, and influenced by the extrapyramidal system. Intact proprioceptive sense, combined with an accurate Nervous System 483 Testing of Muscle Power of Different Muscles Muscle Main Peripheral Test segmental nerve nerve supply Muscles of the neck Eleventh Spinal Patient is asked to flex his neck against resistance a. Nuchal muscles C2, 3 Occipital nerve Patient is asked to extend his neck against resistance Deltoid C Circumflex the patient holds his arm abducted to 60o against the 5 examiner�s resistance Supraspinatus C5 Suprascapular the patient tries to initiate abduction of the arm from the side against resistance Infraspinatus C5 Suprascapular the patient flexes his elbow, holds the elbow to his side, and then attempts to turn the forearm backwards against resistance Rhomboids C5 Nerve to Hand on hip, the patient tries to force his elbow backwards rhomboids Serratus anterior C5, 6, 7 Nerve to the patient pushes his arms forwards against the wall serratus anterior Pectoralis major C6, 7, 8 Lateral and Placing the hand on the hip and pressing inwards; the medial sternocostal part of the muscle can be felt to contract. Raising pectoral nerves the arm forwards above 90� and attempting to adduct it against resistance brings the clavicular portion into action Latissimus dorsi C7 Nerve to a. Resist the patient�s attempt to adduct the arm when abducted to above 90o Biceps C5 Musculocutanous the patient flexes his elbow against resistance, the forearm being supinated Brachio-radialis C5, 6 Radial the patient pronates the forearm and draws the thumb towards the nose against resistance Triceps C7 Radial the patient attempts to extend the flexed elbow against resistance Extensor carpi radialis C6, 7 Radial the patient attempts to dorsiflex his wrist against longus and extensor resistance carpi ulnaris Flexor carpi radialis and C6, 7, 8 Median and the patients attempts to flex his wrist against resistance flexor carpi ulnaris ulnar Abductor pollicis longus C8 Radial the patient attempts to maintain his thumb in abduction against the examiner�s resistance Extensor pollicis brevis C8 Radial the patient attempts to extend the thumb while the examiner attempts to flex it at the metacarpophalangeal joint Extensor pollicis longus C8 Radial the patient attempts to extend the thumb while the examiner attempts to flex it at the interphalangeal joint Flexor pollicis longus C8 Median Attempt is made to flex the distal phalanx of the thumb against the patient�s resistance Opponens pollicis T1 Median the patient attempts to touch the little finger with the thumb. Preserved in ulnar nerve lesions when the rest of the hand appears very wasted Adductor pollicis brevis T1 Median An object is placed in between the thumb and forefinger to prevent full adduction; then the patient attempts to raise the edge of the thumb vertically above the starting point, against resistance. This is an important muscle, being the first to show weakness in carpal tunnel syndrome Adductor pollicis T1 Ulnar the patient attempts to hold a piece of paper between the thumb and the palmar aspect of the forefinger Lumbricals and C8 T1 Median a. Muscle Main Peripheral Test segmental nerve nerve supply Flexor digitorum C8 Median the patient flexes the fingers at the proximal interphalangeal sublimis joint against resistance from the examiner�s fingers placed on the middle phalanx Flexor digitorum C8 Median and the patient flexes the terminal phalanx of the fingers against profundus ulnar resistance, the middle phalanx being supported Abdominal muscles T6�T12 Ilioinguinal, the patient lies on his back and attempts to raise the head iliohypogastric against resistance. In case of lower abdominal muscle weakness, the umbilicus is pulled upwards by the healthy upper abdominal muscles. In case of lesion at the level of T10 spinal segment, the umbilicus moves up by atleast 3 cm on contracting the abdominal muscles Erector spinae muscle All segments Posterior rami of the patient lies prone and then attempts to raise his spinal nerves shoulders off the bed Ilio-psoas L1, 2, 3 Femoral the patient lies on his back and attempts to flex his thigh against resistance Adductor longus L2, 3 Obturator the patient attempts to adduct the leg against resistance Gluteus medius and L4�S1 Superior gluteal the patient, lying prone, flexes the knee and then minimus forces the foot outwards against resistence. These muscles also abduct the extended leg Gluteus maximus L5, S1 Inferior gluteal the patient lying prone, should tighten the buttocks so that each can be palpated and compared; then he is instructed to try to raise the thigh against resistance Hamstrings (biceps, L4, 5 S1, 2 Sciatic the patient lying prone, attempts to flex the knee semitendinosus, against resistance semimembranosus) Quadriceps femoris L3, 4 Femoral the patient, lying on his back, attempts to extend the knee against resistance Tibialis anterior L4,5 Anterior tibial the patient dorsiflexes his foot against the resistance of the examiner�s hand placed across the dorsum of the foot Tibialis posterior L4 Medial popliteal the patient plantar-flexes the foot slightly and then tries to invert it against resistance Peronei L5S1 Musculocutaneous the patient everts the foot against resistance. Isolated weakness may be the earliest sign of peroneal muscular atrophy Gastrocnemius S1 Medial popliteal the patient plantar flexes the foot against resistance Extensor digitorum L5 Anterior tibial the patient dorsiflexes the toes against resistance longus Extensor hallucis L5 Anterior tibial the patient attempts to dorsiflex the great toe longus against resistance Flexor digitorum S1, 2 Medial popliteal the patient flexes the terminal phalanges of the toes longus against resistance image of one�s own body and its relationship to the smoothly is noted and compared with the opposite environment are equally essential for the movement to limb (Fig. The finger-finger-nose test: this test is performed in a therefore produce incoordination. The finger-nose test: In this test, the patient is asked to drawn and the patient is given a pencil and asked to keep his upper limb outstretched and then to touch tap out a series of dots, all within the circle. This act is ataxia, the patient will spread the dots irregularly repeated and the ability to carry out this action over a wide area, outside as well as inside the circle. Dysdiadochokinesis: this is a failure to efficiently perform rapidly alternating movements. This test may be carried out by asking the patient to alternatively and rapidly pronate and supinate the forearm and hand while clapping the other hand. The heel-knee test: the patient is asked to place the heel of one foot over the knee of the other foot and then to move the heel down over the tibia. This test is repeated with the other foot and presence or absence of incoordination is noted (Fig. Foot pat test: the patient is asked to pat the ground with the heels of both feet alternatively in the sitting position. The failure to demonstrate in-coordination when the patient is lying in the bed does not exclude cerebellar Fig. Involuntary Movements Chorea may be seen in the following conditions: A note is made as to the presence of involuntary a. Huntington�s chorea (autosomal dominant condition require careful examination to detect their presence. Senile or arteriosclerotic chorea (occurs in the elderly, They are mainly due to lesions affecting the extrawith sudden onset and with other evidence of degenpyramidal system. Common Involuntary Movements Huntington�s chorea is associated with hypertonia unlike other Chorea (Caudate Nucleus) choreas in which there is hypotonia.

Hormones: chemistry discount symbicort 5mcg asthma pneumonia, mechanism of action and their role in regulation of metabolism and physiological functions consequence of hormonal dysfunction generic symbicort 5 mcg amex asthma treatment article. Immunology: Structure functions purchase 5mcg symbicort mastercard asthma symptoms 2 year old, classifications and synthesis of immunoglobulins cheap 5 mcg symbicort visa asthma 15 month old, antigen-antibody reaction, mechanisms and regulation of immune responses. Complement system, hypersensitivity, immunetolerance, immunity to infection, autoimmunity & auto immune diseases, tumor immunity, genetics of immune response, transplantation, experimental system used in immunology, vaccination and immunization strategies, hybridoma technology. The students undergo training in an environment of advanced research in various aspects biophysics. They receive a sound theoretical knowledge coupled with a demanding practical application. By the end of the course, the student is confident to discuss and dissect any aspect biophysical problem related to clinical sciences. Practical Examination One experiment in any of the biophysical techniques taught one day 3. Viva voce Examination Thesis presentation Bench Viva voce General Viva voce the detailed curriculum to achieve the above objectives is detailed below. It contains four sections of theoretical course and one section of practical course. Besides these, the students require to complete a thesis in any of the research activities of the faculty. To help in acquiring theoretical knowledge, additional resources are indicated in appendix � 1. Mode of action of drugs, quantitative structure-activity relationship, present and future aids to drug-design. Hormones and Drugs Structure and conformation of drugs and receptors, drug-receptor binding forces, haemoglobin as a model receptor, steroid conformation, receptor binding and hormone action, structural aspects of drugnucleic acid interactions. Principles and instrumentation of electron spin resonance, spin hamiltonian and its use to study biomolecules, spin probes and their uses, principles of Mossbauer spectroscopy, quadrupole splitting, isomer chemical shift and magnetic hyperfine splitting, applications of Mossbauer spectroscopy in medicine and biology. Electron Microscopy Basic principles, procedures and applications in biology and medicine. X-Ray Diffraction Techniques Methods of recording the X-ray diffraction patterns: rotation method, Weissenberg method, precession method, precession rotation method and diffractometer methods. Methods of protein structure analysis, crystallization of proteins, symmetry in molecules and crystals, Principle of X-ray diffraction, isomorphous replacement, molecular replacement method. Separation Techniques Basic principles and application of electrophoresis, centrifugation and chromatography. Molecular Modelling Basic principle of modeling, Modeling by energy minimization technique, Concept of rotation about bonds, Energy minimization basic technique for samll molecules. Protein Structure and Function Nature and function of globular proteins, basic principle of protein structure, amino acids, peptide structure, secondary structure of polypeptides and proteins, tertiary structures of haemoglobin, myoglobin, trypsinogen, trypsin, collagen and membrane proteins, interactions of proteins with small molecules and ions. Lipids Structure of lipids, phase changes in lipids, their role in pathogenesis of atherosclerosis, gall stone formation, structure of membranes, membrane receptors, transport across membranes. Contractile proteins Role of contractile proteins in cell function and muscle contraction. Use of imaging devices and external detectors for organ imaging; time dependent and differential functional studies, use of physiological gating techniques for functional studies, methodology and quality control of competitive binding and radio immunoassay, procedures for the measurement of peptide hormones, drugs and other biological substances, basic principles of radionuclide therapy in thyrotoxicosis, carcinoma of thyroid. Single crystal X-ray diffraction patterns from protein crystals using precession method. To simulate alpha helix/beta sheet of protein with given sequences and determine specified angles and distances. An approval of the thesis is essential for the candidate to take the final examination. Aim of postgraduate training is to prepare the students to be � � Teachers � Researchers & Epidemiologists � Health Planners, Organizers and Administrators � Workers in the Community � Other service Personnel in this specialty Towards this end, by the completion of his/her training, the Postgraduate student be : 1. Aware of physical, social, psychological, economic and environmental aspects of health and disease in individual, family and community. Able to apply the clinical skills to recognize and manage common health problems including their physical, emotional, social and economic aspects at the individual and family levels 3. Able to identify, plan and manage the health problems of the community he/she serves. For this, he/she should be able to design a study, collect date, analyse it with appropriate statistical tests and make a report. Identify the health needs and health demands of the community and prioritise the most important problems and help formulate a plan of action to manage them under National Health Programmes guidelines including population control and family welfare programme. He/she should be able to assess and allocate resources, implement and evaluate the programmes. Demonstrate ability of organizing prevention and control of communicable and non-communicable diseases. Organize health care services for special groups like mothers, infants, under-five children, school children, handicapped children and juvenile delinquents etc. Able to co-ordinate with and supervise other members of the health team and maintain liaison with other agencies. Able to promote community participation especially in areas of disease control, health education and implementation of national programmes. Aware of the national priorities and the goals to be achieved to implement primary health care. Definition of health; appreciation of health as a relative concept; determinants of health. Characteristics of agent, host and environmental factors in health and disease and the multifactorial etiology of disease.