Kristy McKiernan Borawski, MD

• Clinical Assistant Professor of Urology
• Department of Urology University of North Carolina?hapel Hill

For people on lincomycin or clindamycin muscle relaxant shot for back pain 100mg voveran sr sale, assess the person for a history of gastrointestinal disease muscle relaxant hydrochloride order cheap voveran sr on line, as antibiotic-associated colitis may occur with these medicines muscle relaxant pills over the counter discount 100 mg voveran sr free shipping. Assess the person for diarrhoea spasms right flank order voveran sr 100mg online, weight loss muscle relaxant oil buy voveran sr master card, weakness and abdominal cramps muscle relaxant drug list voveran sr 100 mg line, which are indicative of the condition. Note that systemic chloramphenicol should not be administered in people with bone marrow depression, or who have had cytotoxic therapy or radiation therapy, as the medicine can cause bone marrow depression, aplastic anaemia and other blood dyscrasias. Caution should be exercised in these conditions because of the increased risk of central toxicity. People with an inflammatory intestinal disorder may have increased absorption of vancomycin and, therefore, a higher risk of toxicity. These people should be assessed carefully and caution should be exercised in administering vancomycin in the presence of these conditions. Exercise caution when using nitrofurantoin in people with peripheral neuropathy and respiratory disease, as these conditions may worsen. Ensure that emergency equipment and medicines are available in case of anaphylaxis, especially for penicillin and cephalosporin therapy. Administer antibacterial agents at equal intervals over the day to maintain blood levels. Monitor the white blood cell count, which tends to increase during an infection and decrease as the infection is resolved. Note that antibacterial agents can cause electrolyte and fluid disturbances from the type of preparation, or from adverse effects such as diarrhoea. More common electrolyte imbalances include hypernatraemia (from antibacterials made with a sodium base) and hypokalaemia (from severe diarrhoea or the administration of an antibacterial agent containing a large amount of sodium). An extracellular volume excess can occur from administering multiple antibacterial agents (and intravenous medicines) in a diluted form. Monitor for manifestations of superinfection, especially if the person is taking high doses for a prolonged period. Manifestations may include anal or genital discharge, anal or genital itching, or stomatitis (see Chapter 11, Tables 11. Once results of tests are known, a more specific antibacterial agent may be administered. Note that cultures taken after antibacterial agents or paracetamol have been commenced are not very reliable. Dilute antibacterial agents for intravenous use in a suitable volume for administration according to product information. Ensure that intravenous antibacterial agents are administered alone and not in the presence of other medicines or infusions, to prevent incompatibilities. Note whether the health care institution has a policy for the administration of antibacterial agents. Such policies contain guidelines that restrict the administration of antibacterial agents to a specific time period to help prevent antibacterial resistance. Prophylactic treatment with antibacterial agents should be restricted to certain clinical conditions and surgical procedures with a high risk of infection, such as postsplenectomy, prevention of recurrent rheumatic fever, abdominal surgery, coronary bypass surgery and amputation of a gangrenous limb. Topical antibacterial agents should be avoided as they can increase sensitisation and resistance. Treatment with ophthalmic antibacterial preparations, and with topical preparations not generally available for systemic administration. Certain oral penicillins are not affected by gastric acid and can be taken without concern about meals. Do not administer intravenous penicillins too quickly, as rapid administration has been associated with seizures. Be aware that preparations containing benzathine or procaine are never given intravenously. Generally, intravenous penicillins are physically incompatible with other medicines and should be administered separately. Administer one hour before or two hours after meals to decrease destruction by gastric acid. If the intravenous form of vancomycin has been ordered for oral use, the contents of the vial are dissolved with about 30 mL of water or juice. Administer straight, or through a nasogastric tube to minimise the unpleasant taste. Monitor trough levels of vancomycin in certain conditions, such as endocarditis, cellulitis or meningitis. Teicoplanin can be given once daily and does not usually require monitoring of serum levels. Hearing loss may be worsened when these medicines are combined with other ototoxic therapies, such as aminoglycosides. Monitor the renal function and full blood profile at least weekly for people receiving teicoplanin or vancomycin. For people receiving teicoplanin or vancomycin, avoid administering other potentially nephrotoxic or ototoxic medicines, such as aminoglycosides. Administer oral macrolides with a full glass of water on an empty stomach (one hour before or two hours after meals) to create maximum effect. Enteric-coated, sustained-release preparations can be administered with food and are often prescribed for people with a gastrointestinal intolerance. When administering oral suspensions, ensure that they are shaken well and refrigerated after opening. If treatment is to continue for less than 48 hours, drug concentration monitoring is not required in people with normal renal function. For treatment longer than 48 hours, drug concentration and creatinine clearance should be checked every three to five days in clinically stable people, and daily in people with some form of clinical instability, such as renal impairment. The person should not receive a dose more often than every 12 hours except in specific circumstances, such as bacterial endocarditis and burns. Monitor the person on systemic chloramphenicol for pale skin, sore throat, fever, unexplained bruising or bleeding, leukopoenia and thrombocytopenia. Sodium fusidate should be administered with other antibacterial agents, as resistance develops quickly when it is given as a sole antibacterial. Cease treatment immediately if diarrhoea or antibioticinduced colitis occurs during lincomycin or clindamycin treatment. Do not administer antidiarrhoeal agents to treat diarrhoea due to the possible retention of toxins and worsening of the condition. The absorption of tetracyclines can be influenced by the presence of food and other medicines. Erythromycin and Advise the person that, after using rifampicin or rifabutin, their urine, faeces, sweat and tears may become orange-red. Their contact lenses may also be permanently stained after using rifampicin or rifabutin, and should therefore be avoided. Advise women that rifampicin or rifabutin can make the contraceptive pill less effective and they are advised to use additional sources of contraception. Treatment should be stopped if eosinophilic pneumonia or peripheral neuropathy occur. Instruct the person to complete the prescribed course of treatment over the required period. Discontinuing the medicine prematurely may mean the infection is not fully treated and may lead to antibiotic resistance. Advise on the importance of maintaining equal time intervals for administration to ensure sustained blood levels. If an allergic reaction occurs, the antibacterial agent should be discontinued immediately and the doctor notified. The preparation should not be frozen, and the person must shake the container thoroughly before administration. The preparation can hydrolyse rapidly to form a substance that can cause pulmonary toxicity. A bronchodilator should be administered before inhalation therapy to prevent bronchospasm. Monitor people for nephrotoxicity as shown by raised serum potassium, creatinine and urea levels, and lowered urinary output. Also monitor for neurotoxicity as shown by numbness, tingling of extremities and dizziness. Ensure that respiratory emergency equipment is close by and readily available in case of pulmonary toxicity after inhalation therapy. Monitor urinary output and ensure that the person maintains a urine output of more than 1200 mL per day to minimise the incidence of crystalluria. Treatment should cease at the first sign of tendon or joint pain and inflammation. Advise people to take cephalosporins on an empty stomach, although they may be taken with food if gastric irritation occurs. Instruct the person that tetracyclines can cause photosensitivity reactions, and to avoid the sun during the warmest time of day (10 am to 4 pm), use a sunscreen, and wear a hat and protective clothing (see Chapter 11, Table 11. These have been associated with toxic reactions from the breakdown products of tetracycline. Warn people taking minocycline to avoid driving or operating heavy machinery if they experience dizziness. Women on the contraceptive pill should use additional barrier methods of contraception, as tetracyclines have been associated with decreased effectiveness of the pill. Inform the person that capsules or tablets should be taken with a large glass of water. The person should then be advised not to lie down within one hour of taking the preparation to prevent it from becoming lodged in the oesophagus. Instruct the person on chloramphenicol to delay all dental work until the blood count is verified as normal. Teach the person about the importance of oral hygiene, with cautious use of toothbrushes (use a soft brush), dental floss and toothpicks. Advise the person on sodium fusidate to take the antibacterial agent after meals to reduce the incidence of gastric irritation. Encourage the person to consume large quantities of fluid (to wash out the microorganisms more easily) and to consume fluids with a high vitamin C content, such as orange juice. Advise the person to avoid driving or operating heavy machinery, as dizziness and drowsiness may occur. Instruct the person to take the antibacterial agent after meals to prevent gastric irritation. Suspensions should be shaken well before administration and kept in the refrigerator once opened. Advise the person to ensure that adequate fluids are consumed to maintain a high urinary output, therefore preventing crystalluria. If these manifestations occur, the person should avoid driving or operating heavy machinery. Warn the person that photosensitivity may occur and to avoid sun exposure (see Chapter 11, Table 11. Inform the person that quinolone preparations may increase the stimulatory effects of caffeine. Advise the person on lincomycin or clindamycin to report the development of diarrhoea. Advise the person to take oral clindamycin with a full glass of water, with or without meals. Advise the person to take oral chloramphenicol with a full glass of water on an empty stomach. Advise people on chloramphenicol to avoid driving or operating heavy machinery if confusion or visual disturbances occur. Advise the person on chloramphenicol to report any manifestations of blood dyscrasias, such as sore throat, weakness, unexplained bruising or bleeding, and fever. Evaluation Inform the person to take the preparation with or immediately after meals. Advise the person to stop taking metronidazole and to see the doctor immediately if numbness, tingling, pain or weakness occurs in the hands or feet. For systemic infection, evaluate the return to normal of the temperature, pulse rate, respiratory rate and white blood cell count. If purulent discharge is present, evaluate the presence of a decreased amount and a more normal appearance and consistency. Antibacterial groups that act by inhibiting protein synthesis include the aminoglycosides, the tetracyclines, the macrolides, the streptogramins, the oxazolidinones and the lincosamides. Allergies occur in about 10 per cent of individuals receiving penicillins, and anaphylaxis occurs in 0. Renal and hepatic functions should be monitored during prolonged high-dose antibacterial therapy. With large doses or prolonged antibacterial therapy, bacterial or fungal superinfection may occur, especially in older, debilitated or immunosuppressed people. People receiving aminoglycoside therapy for more than 72 hours should be monitored for signs of toxicity, including ototoxicity and renal impairment.

Syndromes

• Gargle with salt water or cool water.
• Have high blood pressure that does get lower with medicine.
• Itraconazole
• Movement difficulty
• Headache
• The tubing near the access port can be accidentally punctured during a needle access. If this happens the band cannot be tightened (you would need minor surgery to fix this problem)
• Gingivitis (inflammation of the gums)
• Pulmonary function tests (if kyphosis affects breathing)

Renal function should be monitored regularly during therapy with cidofovir spasms constipation cheap 100 mg voveran sr free shipping, foscarnet or ganciclovir muscle relaxant abuse buy voveran sr with american express. Inform people to avoid driving or using machinery if valganciclovir makes them drowsy muscle relaxant brand names buy voveran sr 100 mg free shipping. Clinical considerations In view of their potential vision-threatening e ects spasms lower left abdomen cheapest voveran sr, topical ocular corticosteroids muscle spasms 7 little words order voveran sr 100 mg without prescription, used alone or in combination with antibacterial agents muscle relaxant for anxiety purchase voveran sr 100 mg fast delivery, should be prescribed only under close supervision by a quali ed ophthalmologist. Treatment is not extended beyond two weeks, and the ophthalmologist may need to monitor ocular pressure and integrity of the corneal epithelium. Antimuscarinic agents related to atropine act by the former mechanism and sympathomimetic agents related to noradrenaline induce the latter. Mydriatic agents are used for the purposes of ophthalmic examination and surgery, in in ammatory conditions involving the iris or ciliary body, and in testing the optical properties of the eye. General clinical considerations To reduce initial stinging caused by mydriatrics, advise people to close their eyes and to avoid rubbing immediately a er instillation. Many of the corticosteroids used in ophthalmic preparations are quite potent and include dexamethasone, uorometholone, hydrocortisone, prednisone and prednisolone. Common adverse effects As you might expect, the potential to cause harm during treatment with these medicines is high. As corticosteroids tend to depress immune responsiveness, they are usually combined with ophthalmic antibacterial agents when used in the treatment of bacterial infections because of their potential to worsen the infection. Indeed, corticosteroids are contraindicated in viral infections of the cornea and conjunctiva because they actually enhance the development of the infection. In any eye condition characterised by thinning of the cornea, corticosteroid treatment can cause perforation. Other adverse reactions to watch out for during this therapy are the development of glaucoma in susceptible individuals (see Chapter 19) and cataract formation associated with long-term use. Intraocular pressure and lens structure need to be monitored regularly during treatment. As a result the suspensory ligaments attached to the lens become taut, and the lens stretches and becomes atter, focused for far vision. As the ciliary muscle is deep within the eyeball, the ability of the antimuscarinic mydriatics to cause cycloplegia depends on their rate of absorption, duration of action and potency. Common ophthalmic antimuscarinic mydriatics include atropine, cyclopentolate, homatropine (only available in Australia) and tropicamide. Clinical considerations Atropine is potent and long-acting: its e ects may last for days a er administration. Lignocaine is used in combination with the stain uorescein (see the section on stains later in this chapter). Mechanism of action Local anaesthetics impair nerve transmission by inhibiting the movement of sodium ions across the nerve membrane and, in e ect, blocking depolarisation. Common adverse effects Common adverse reactions include eye irritation, stinging, burning, photophobia, conjunctival injection (a dilation of conjunctival blood vessels) and allergic reactions. Clinical considerations It is important to warn people beforehand that local anaesthetics can cause initial stinging. To reduce the stinging, people are instructed to close their eyes a er instillation, and to dab away the tears without rubbing the eyes. Applied topically they constrict ocular blood vessels, counteracting conjunctival hyperaemia and congestion. Speci c drugs in this group include phenylephrine, naphazoline and tetrahydrozoline. Members of this group that are poorly absorbed through the cornea, such as naphazoline, produce e ective decongestion with little mydriasis. Common adverse effects e main concern about these agents is the degree of systemic absorption through the conjunctival vasculature directly and nasal mucosa a er nasolacrimal drainage. Systemic adverse reactions include hypertension, tachycardia and anxiety; hence, topical sympathomimetics should be used with caution in people with hypertension, heart disease or thyrotoxicosis. Clinical considerations Systemic absorption can be reduced by pressing against the tear duct and by closing the eye for about three minutes a er instillation. Open-angle glaucoma is by far the more common form, accounting for around 90 per cent of cases, and is responsive to drug therapy. It is characterised by impaired di usion of aqueous humour through the trabecular network to the canal of Schlemm, where absorption of this humour occurs. B In open-angle glaucoma, the trabeculae proliferate, making the drainage of aqueous humour more di cult. C In closed-angle glaucoma, when the iris bulges during pupil dilation, the drainage pathway is completely closed. Lens Iris Normal angle Trabeculae Canal of Schlemm A Normal Open angle Proliferated trabeculae B Open-angle C Closed-angle Closed angle Closed-angle (also known as narrow-angle or angle closure) glaucoma arises when the anterior chamber is narrow and the canal of Schlemm is completely obstructed as the iris thickens during pupil dilation. Most of the agents used in the treatment of open-angle glaucoma are used also in the acute management of narrow-angle glaucoma prior to the operation. Broadly speaking, the drugs used either reduce the formation of aqueous humour or enhance the drainage of aqueous humour from the eye. In clinical practice, medicines with each action may be combined in therapy, and work synergistically (see Chapter 16) to control the condition. Betaxolol is relatively selective for 1 receptors, while the other two are non-selective -blockers. Common adverse effects Common adverse e ects include paraesthesias, dry eyes, blurred vision and eye irritation. Systemic absorption is observed and the generalised adverse e ects associated with this treatment can include bronchospasm in people with asthma (less of a risk when betaxolol is used), bradycardia and a masking of the manifestations of hypoglycaemia. Contraindications for use include severe cardiac disease or an acute asthma attack. Clinical considerations Some people may need a few weeks of treatment to stabilise the pressure-lowering response. Advise people to monitor the pulse rate and to report a slow rate to the prescriber. People aged 65 years and over are more likely to experience systemic adverse e ects with these medicines such as hypotension, which predisposes them to falls. Mechanism of action ese act primarily to increase the drainage of aqueous humour out of the anterior cavity through the canal of Schlemm. Common adverse effects Systemic adverse e ects are few, headache being the most common. Clinical considerations Carbachol is available in the form of eye drops and an intraocular injection. Advise people on muscarinic agonists to exercise caution during night-time driving and when performing hazardous activities in poor light. People will need to remain under medical supervision for periodic tonometric readings. Acetylcholine cannot be applied topically to the surface of an intact eye because it is degraded by acetylcholinesterase before it can produce its clinical e ect. It is reserved for intraocular injection into the anterior chamber during eye surgery, particularly in cataract operations. Solutions of acetylcholine are very unstable; therefore, they need to be prepared immediately before use and the excess discarded a erwards. Adverse e ects are observed rarely and include corneal oedema, clouding and decompensation. Systemic adverse e ects are rare, but when observed include bradycardia, breathing di culties and sweating. Mechanism of action e sympathomimetics can decrease the formation of aqueous humour and increase its out ow. Adrenaline can decrease the production of aqueous humour and enhance its drainage from the eye through a combination of and receptor e ects on the ciliary body. It is interesting that pharmacological antagonists like adrenaline and the -blockers both produce falls in intraocular pressure. Apraclonidine is related to the antihypertensive agent clonidine (see Chapters 27 and 46). It is a relatively selective 2 agonist which, through prejunctional receptor activation (see Chapter 27), produces the desired ophthalmic e ects. A major advantage of this receptor selectivity is the absence of the mydriasis associated with other ophthalmic sympathomimetic agents. However, when compared with the -blockers, the reduction in intraocular pressure produced by brimonidine is small, and it appears to have more adverse e ects. Common adverse effects Common adverse e ects of phenylephrine include headache, a stinging sensation during instillation, mydriasis and blurred vision. Topical administration greatly reduces systemic absorption, but the person should be monitored for changes in heart rate, rhythm and blood pressure, as well as anxiety and tremor. An important contraindication for use is in the treatment of closed-angle glaucoma (where mydriasis would aggravate the condition). Common adverse e ects of the 2-selective agonists include ocular hyperaemia, pruritus and discomfort. Systemic absorption of apraclonidine can occur, resulting in headache, a dry mouth and chest pain. Its use is restricted to monotherapy for those with open-angle glaucoma who cannot take -blockers. Clinical considerations Apraclonidine should be used only in the short term for lowering the intraocular pressure, as it is associated with allergic blepharoconjunctivitis with chronic use. Interestingly, there is a combined preparation of brimonidine and the non-selective -blocker timolol available for the management of glaucoma. Clinical considerations Acetazolamide is administered orally in the form of tablets and intravenously. Systemic therapy with acetazolamide is usually avoided because of the high incidence of adverse e ects. Topical carbonic anhydrase inhibitors such as brinzolamide or dorzolamide may cause temporary discomfort a er instillation. If the person experiences blurred vision, driving or operating machinery should be avoided until the sight improves. Clinical studies indicate that the e cacy of these medicines in reducing intraocular pressure is comparable with the -blocker timolol. Common adverse effects Common adverse reactions are stinging, burning, itching, hyperaemia, redness of the eye, lengthening and increased number of eyelashes, and blurred vision. Interestingly, a signi cant proportion of individuals who receive this medicine for a prolonged period report a change in eye colour due to altered iris pigmentation. Mechanism of action As the name suggests, carbonic anhydrase inhibitors act on the enzyme responsible for the conversion of carbon dioxide to bicarbonate and hydrogen ions (and back again). In the eye, carbonic anhydrase plays a signi cant role in aqueous humour formation by the ciliary body cells. In the ciliary bodies, carbonic anhydrase facilitates the secretion of bicarbonate ions into the aqueous humour. Carbonic anhydrase inhibitors, therefore, decrease the formation of aqueous humour. Glaucoma has become the main clinical indication for the carbonic anhydrase inhibitors. Brinzolamide and dorzolamide are available in a topical preparation, so the incidence of systemic adverse e ects is minimised. Common adverse effects e carbonic anhydrase inhibitors are closely related to the sulfonamide antibacterial agents. As such, they produce a similar pro le of adverse e ects, including skin rashes, kidney stones and aplastic anaemia. It is important to warn people, especially those with green eyes, of a possible change in iris pigmentation, which is an irreversible condition. Sodium hyaluronate is the salt of hyaluronic acid, a normal component of connective tissue matrix. Hyaluronic acid is considered a type of intracellular cement holding the matrix together. Common adverse effects A common adverse e ect of sodium hyaluronate is a transient rise in intraocular pressure postoperatively. Clinical considerations ese preparations are stored in the refrigerator and protected from freezing. It is approved for use in combination with a -blocker in the management of intraocular pressure in chronic open-angle glaucoma and in ocular hypertension that does not respond to monotherapy. Mechanism of action Prostamides are naturally occurring substances that are related to the eicosanoids (see Chapter 31). Bimatoprost selectively mimics the e ects of prostamide and has shown itself to be a potent ocular hypotensive agent in reducing intraocular pressure. Common adverse effects Common adverse e ects include ocular hyperaemia, itching and growth of eyelashes. Systemic absorption of the eye drops can be minimised by applying pressure to the tear duct a er administration. It is a longacting agent that needs to be administered only once daily, preferably at night. Its systemic absorption from the eye is signi cant and requires metabolism by the liver. When injected into connective tissue, hyaluronidase makes the tissue more permeable and enhances the dispersion and absorption of the anaesthetic. It is contraindicated in infection and malignancy, as it could enhance the spread of infectious agents or malignant cells. As you might imagine, this is problematic during surgery, as it a ects access to the lens. An increased bleeding tendency during ocular surgery has been reported for urbiprofen. Clinical considerations When used topically, these anti-in ammatory agents can mask symptoms of ocular infections.

In palliative care spasms of the larynx cheap 100mg voveran sr with visa, if addiction does occur muscle relaxants generic voveran sr 100 mg with mastercard, the bene ts of continuing treatment are usually considered greater than this problem spasms face buy voveran sr with paypal. From a functional point of view spasm buy voveran sr 100mg on line, one type is called productive pain muscle relaxant usa buy 100 mg voveran sr fast delivery, which occurs immediately a er tissue damage spasms sternum 100mg voveran sr sale. For example, if you touch something hot you can react to the pain by withdrawing your hand, avoiding further tissue damage. Another type of pain is termed non-productive pain and, even though it is o en caused by tissue injury, one has minimal control over it. Visceral pain emanates from the internal organs and involuntary tissues of the torso. Musculoskeletal pain, also termed somatic pain, responds well to the non-narcotic analgesics. Pain that originates in the nervous system associated with the remodelling of neural connectivity caused by chronic injury or disease, called neuropathic pain, requires treatment with medicines not normally considered to be analgesics-for example, using phenytoin or carbamazepine to treat trigeminal neuralgia (see Chapter 38). Chronic pain is prolonged (lasting longer than six months), with a variable response pattern in which it is harder to evaluate the pain, treatment rarely o ers complete relief and su ering tends to increase over time. Pain transmission (Nociception) Nociception starts in the periphery with the stimulation of pain receptors connected to a erent nerve bres termed nociceptive neurones. Large-diameter myelinated bres are called A bres and conduct impulses very quickly. For example, warm water will stimulate heat receptors in the skin to record the sensation of warmth, but scalding water leads to tissue damage and then only the nociceptive bres are stimulated. In other words, some pain receptors have a higher threshold for activation than purely thermal (or mechanical-type) receptors. A erent nociceptive bres synapse in the spinal cord within an area of the dorsal grey horn called the substantia gelatinosa. Secondary a erent bres convey information along ascending pathways to the brain for processing. In pain transmission, the spinothalamic tracts are the most important ascending pathways. Within the brain the information is sorted in the thalamus and sent to the appropriate region of the cortex for nal processing. Pain information is also processed in the brainstem, hypothalamus, midbrain and limbic areas. In some cases the modulation can lead to enhanced pain sensations, and in others the pain is suppressed. As yet there are no therapeutic substances currently available to speci cally inhibit the action of kinins (although there are some being tested at the research stage); however, peripheral pain transmission can be suppressed to induce analgesia through the use of inhibitors of prostaglandin synthesis (see Chapter 41). However, it remains on the receptors and e ectively blocks the pain transmission, producing analgesia. Capsaicin stimulates the release of substance P; on continued application, substance P stores are exhausted and no more pain transmission can occur. As is commonly known, capsaicin is found in products such as chilli and curry powders and can produce severe burning sensations on the tongue. If one continues to consume these hot chillies, substance P stores get depleted and the burning sensations decrease. Capsaicin may be included in rubefacients, a form of topical analgesic preparation that gets its name from its property of turning the skin to which it is applied red (see Chapter 82). It is in uenced by many factors, including culture, prognosis, diagnosis, coping strategies, values, fear and anxiety. In this model, narcotic and non-narcotic medicines are progressively administered until pain is relieved. Marathon runners, while approaching the nishing line, are o en not aware of the physical agonies that their bodies are su ering until a er the end of a race. Football players as blood pressure, pulse and respirations regularly, pain assessment is sometimes not examined routinely. If people experience acute or chronic pain, it is important that they be assessed during movement, activity and rest, and that the e ects of analgesics be closely evaluated for alleviation of pain. Self-reports form part of a pain history that should be documented for all those with a type of acute or chronic pain. While the exact details on the chart may di er between institutions, it will contain information about the analgesic dose route, pain rating, vital signs, level of arousal and activity, and adverse reactions to the administered analgesic. People in road accidents can be fully conscious but unaware of horrendous damage to their bodies. Several of these compounds have been identi ed so far, with the general names of endorphins, enkephalins or dynorphins. For example, metencephalin is found in the myenteric plexus, where it is involved in inhibiting the release of acetylcholine. At least four di erent opioid receptors for these compounds have been identi ed, and they help to explain the di ering properties of the opioids. Indeed, a number of subtypes of opioid receptors have recently been identi ed, including at least three (mu) receptor subtypes. At the cellular level, the opioid receptors are G-proteincoupled receptors linked to both the membrane-bound enzyme adenylate cyclase and potassium channels in the nerve membrane. Generally, these e ects decrease neuronal excitability and reduce pain processing. Euphoria can be of some clinical bene t, especially with the terminally ill, as a feeling of wellbeing helps the person cope with the present situation. Many people, when given narcotic analgesics, are still very much aware of pain but it does not bother them: the feeling of euphoria pushes the pain away and it is reduced to a minor irritation. Common adverse effects Unfortunately, these medicines have many adverse e ects, and the problem of addiction (physical dependence) creates dilemmas regarding their use. A phenomenon in health care that is characterised by excessive fear of narcotic addiction has led to the coining of the term opiophobia. Addiction to narcotics within the clinical setting has been overstated; when they are used for the appropriate treatment of severe pain, physical dependence is not usually a problem. When these medicines are used solely for recreational purposes, the risk of addiction is, of course, very high. When physical dependence develops, withdrawal symptoms will develop when the narcotic is discontinued. Withdrawal symptoms from narcotic dependence can be severe, but they are not as dangerous as the withdrawal symptoms of alcohol or barbiturate addiction. Symptoms are variable but include an increase in ow of most body uids, resulting in lacrimation, rhinorrhoea, diarrhoea and sometimes even spermatorrhoea. In withdrawal a person may experience severe psychological disturbances, which o en necessitate psychiatric treatment. Stimulation of this area can lead to severe nausea and vomiting, sometimes enough to incapacitate the person and to lead to non-adherence to treatment. Stimulation of these receptors causes an increase in segmentation-type contractions and a simultaneous decrease in peristaltic movements. Careful attendance to bowel habits is of the utmost importance when using these medicines, and the judicious use of laxatives is usually required. Morphine and some other narcotics are also known to inhibit stomach, pancreatic, biliary and intestinal secretions. Narcotics contract biliary smooth muscle, which may result in a spasm in the biliary tract, and are o en contraindicated in the management of pain from biliary colic. Some doctors still use opioids for both biliary and renal colic in a high enough dose to overcome the pain caused by the rise in duct pressure. Pethidine has little action on smooth muscle, and may be used in the treatment of the pain of smooth muscle spasm. Because of its minimal e ect on gastrointestinal smooth muscle, pethidine is devoid of a constipating e ect. Pethidine is less likely to cause respiratory depression and is of no value as a cough suppressant. Tolerance develops fairly rapidly to the euphoric and analgesic properties of the narcotics but relatively slowly to the e ects on the respiratory centre. Miosis (pupil constriction) occurs with the narcotic medicines, and is associated with parasympathetic activation of the iris muscle. Tolerance does not develop to this miosis and it is di cult to disguise constricted pupils when narcotic abuse is taking place. Histamine release is also triggered by a number of the narcotic medicines, including morphine. Sweating, urticaria and pruritus may also be observed when these medicines are administered. When changing narcotic analgesics, it is important to consider their equianalgesic dose compared with morphine. Usually, 10 mg of intramuscular or subcutaneous morphine is considered the standard to which others are compared. It is generally wise to start with a slightly lower dose when changing between narcotic analgesics because of incomplete cross-tolerance. Other narcotic analgesics may be used if the adverse e ects of morphine are poorly tolerated. Pethidine is not currently recommended as a rst-line treatment for pain because of potential toxicity problems associated with multiple dosing (see below). Morphine Morphine was the rst narcotic agent to be introduced as a single analgesic agent and it remains the mainstay analgesic, in spite of the availability of a succession of more potent medicines. Morphine has a short half-life, about four hours, so frequent dosing is required for conventional preparations. Controlled-release preparations are not used for acute pain management because they have a slow onset, slow diminishment of the e ect and a long duration of action, making titration of analgesic e ect very di cult. Contraindicated in renal failure and with medicines that increase serotonin concentration. Due to varied response only one-half to two-thirds dose administered in rst few doses. Avoid use as analgesic because slow onset of action and e ect not reversed by naloxone. It is available in Australasia as a cough suppressant, and is formulated with aspirin in over-the-counter analgesics. Dihydrocodeine is a better analgesic than codeine and it has fewer adverse e ects and a lower abuse potential than morphine. Codeine Codeine is chemically closely related to morphine but is much less potent. Much of the analgesic activity of codeine may be related to its partial conversion into morphine in the liver. Approximately ten per cent of the population is lacking the enzyme responsible for this conversion. Codeine at a dose of 120 mg produces the equivalent e ect of about 10 mg of morphine. However, the potential for abuse does exist, and the higherdose combinations should not be used indiscriminately. Heroin Surprisingly, heroin (diacetylmorphine or diamorphine) was initially introduced as an alternative to morphine in cases of addiction. In fact, the opposite is true-because of this, heroin is an illegal drug in most countries, including Australia and New Zealand. A er this the a ected person experiences an hour or so of sedation, lethargy, a sense of serenity and sleep. Some would argue that the greater euphoric e ect given by heroin is advantageous in the terminally ill, and that it should be legalised again because of this e ect. Another advantage that heroin has over morphine is that it is much more soluble than morphine and less volume has to be injected. If heroin is taken orally it is almost completely converted to morphine during the hepatic rst pass and so it is not given by this route. It is usually administered by intravenous injection, but it can also be smoked or snorted. An interesting fact about heroin is that it is metabolised to morphine and monoacetyl morphine, the latter of which can be detected in urine and is generally indicative of heroin rather than morphine use. As has been said, heroin is illegal in most countries, and proof of consumption is obtained from detecting monoacetyl morphine. Dihydrocodeine is derivative of codeine has been available in many countries for several decades as a moderately potent analgesic. All potential drugs synthesised by pharmaceutical companies Pethidine Pethidine, like morphine, has a high hepatic rst pass; hence, the parenteral dose is lower than that of the oral dose. Pethidine is occasionally used as an analgesic in labour as it does not suppress uterine contractions; but it must be remembered that the fetal respiratory rate may be a ected. Unfortunately, pethidine is associated with several problems, and its routine use for the treatment of moderate to severe pain is no longer recommended. Norpethidine has a longer half-life than pethidine, and the concentration of this metabolite can rise to toxic levels during frequent dosing over several days. Analgesic treatment with pethidine in combination with medicines that increase serotonin levels. It is extremely toxic in cases of overdose as it can produce prolongation of the Q-T interval and torsaides de pointes, which is a potentially lethal cardiac dysrrhythmia. Tramadol Tramadol is unlike all other opioids that are used therapeutically in the control of moderate to severe pain in that it almost never produces euphoria, tolerance or addiction.

In talking with his friends spasms calf muscles purchase voveran sr online pills, he nds out that phentermine is an e ective medicine to encourage weight loss spasms upper left abdomen order 100 mg voveran sr otc. This became an obsession muscle relaxant baclofen cheap voveran sr 100 mg on-line, so much so that she started to shed the kilograms at an alarming rate muscle relaxant constipation cheap voveran sr uk, trying out one diet after another muscle relaxant tinnitus order voveran sr 100 mg on-line. She was still not satis ed and managed to get hold of phentermine tablets spasms down there buy discount voveran sr 100 mg, which she took daily. Her menstrual periods stopped, and she became depressed because she still thought of herself as being fat. Her parents at last managed to get her to visit her general practitioner, who referred her to a psychiatrist; anorexia nervosa was diagnosed. This, together with uoxetine, tri uoperazine and orphenadrine, soon improved her mood. She was discharged from hospital after six weeks, although was still taking uoxetine. With weekly visits to her psychiatrist, she continued to improve both physically and mentally and the uoxetine was gradually withdrawn, so that after a year she was no longer on this therapy. She commenced treatment with high doses of the thionamide carbimazole as well as the -blocker metoprolol. What advice should be given to people taking thionamides regarding the onset of clinical e ects What adverse e ect must be closely monitored for during the rst weeks of thionamide therapy What is the purpose of administering iodine solution prior to thyroid surgery, and what is the mechanism of action of this medicine Furthermore, she has been talking to friends and they have told her about progestogen-only oral contraceptives. High-dose progestogen-only preparations are one form of hormone-based emergency contraception. If so, compare the e cacy and adverse e ects of these with progestogen-only preparations. What are the advantages and disadvantages of the progestogen-only oral contraceptives He is prescribed oral hypoglycaemic therapy-the biguanide metformin and the postprandial agent acarbose. She complains of heartburn over the past few days, which appears to have become worse. Over the past two days he has been urinating frequently and drinking more uids than he usually does. He has a normal blood pressure, does not have a fever, there is no evidence of oedema and his pulses are normal. When should the vitamin D supplement be administered in relation to alendronate sodium Outline the medicine education that should be given in relation to alendronate sodium therapy. He is prescribed a course of therapy with dutasteride capsules by his genito-urinary consultant. Therapeutic Guidelines Ltd, 2009, Therapeutic Guidelines: Endocrinology, 4th edn, Therapeutic Guidelines, Melbourne. The types of nutrients required for adequate nutrition include vitamins, minerals, amino acids, fats and carbohydrates. Sometimes circumstances arise where adequate nutrition cannot be maintained by eating. This might be due to conditions such as a digestive disorder, surgery, coma, or nausea and vomiting. At other times a person may not be relied on to eat a healthy diet or even su cient food. In such cases, nutritional support may be required, supplied by either the enteral (via the gastrointestinal tract) or parenteral (intravenous) route. As well as being involved in disease processes, some nutrients can actually be used as therapeutic substances-not only as dietary supplements but as medicines. In this section, we examine the functions and uses of vitamins, minerals and amino acids (Chapter 67). The principles of enteral and parenteral nutritional therapy are described in Chapter 68, and Chapter 69 deals with a variety of herbal medicines. As many people take herbal medicines it is important that health professionals have some knowledge of the common preparations available. All these substances work in complex ways to enable metabolic processes to occur e ciently in the body. It was initially believed that these substances, found in foodstu s and necessary to the diet, were organic amines. Vitamins are a very diverse group of organic substances needed for metabolic processes that take place in the body. In view of the many vitamin preparations that are sold in pharmacies, supermarkets and health food stores, it is important that health professionals know something about them and the apparent fallacies that are associated with them. Vitamins, when consumed in food, cannot be termed medicines, but when taken as supplements can be so classi ed. Most authorities classify vitamins into two main groups: fat-soluble and water-soluble. All of these fatsoluble vitamins (as is true for any lipid) depend on bile for their absorption, and any disturbance in bile formation can lead to de ciencies. As vitamin D has a major in uence on bone metabolism, its characteristics and uses are described in Chapter 64. Generally, fat-soluble vitamins are stored for considerable periods in the body, whereas the water-soluble ones are not. However, vitamin B12, a watersoluble vitamin, can be stored for months in the liver. When examining the vitamins, it is easy to start with vitamin A and consider them in alphabetical order. Additionally, smokers certainly require greater amounts of vitamin C than non-smokers. A er various chemical modi cations, some retinoids are very potent medicines, used mainly in the treatment of psoriasis and acne (as discussed in Chapter 82). Polar bear liver is so high in retinol that it must be considered toxic, as early Arctic explorers found out to their detriment. Retinol is not found in plant products, but fortunately most plants contain substances called carotenoids, which act as provitamins and can be converted into retinol in our intestinal wall and liver. Any vegetable or fruit that has an orange colour will usually contain this provitamin. In fact, next to carrots, spinach has the highest concentration of -carotene of all other commonly eaten fruit and vegetables. First, vitamin A is needed for the formation of visual purple, a light-sensitive pigment of the retina of the eye. Retinal combines with proteins called opsins, resulting in the formation of four types of coloured compounds called visual pigments. Recalling your learning in anatomy, you may remember that the retina is dark due to the presence of these pigments. It is not necessary to go into detail here except to explain brie y the function of one of these pigments, which is greatly a ected by vitamin A de ciency. When low-intensity light acts on rhodopsin, the photochemical changes eventually result in graded potentials. If rhodopsin is lacking, this series of events is inhibited, and what is called night blindness (or nyctalopia) results. Second, vitamin A is needed for the normal growth and di erentiation of epithelial tissues, and probably the di erentiation of all tissues. It is primarily involved with the normal functioning of mucus-secreting epithelial cells. For example, -carotene has been used in Western Australia to treat mesothelioma of the lung, caused by asbestos. It appears that people with diets containing fruit and vegetables high in -carotene have a lower incidence of certain cancers and cardiovascular disease. Many chemicals found in a normal diet may have carcinogenic potential when oxidised: -carotene may prevent these changes from occurring. Likewise, atherosclerosis and cardiac dysrhythmias may be due to a lack of certain unsaturated fatty acids, such as linoleic acid. Even if linoleic acid is present in the diet it can be oxidised in vivo: -carotene and other antioxidants may prevent this reaction from happening. As already mentioned, the retinoids can be toxic if taken in excess, and they are teratogenic. Symptoms of toxicity are varied and can include excessive peeling of the skin, hyperlipidaemia, hypercalcaemia and hepatotoxicity. An acute dose of about 200 mg can cause immediate toxicity, resulting in increased cerebrospinal pressure. A large-scale, placebo-controlled trial carried out in the United States using -carotene was terminated prematurely, as it appeared that the people on the active compound showed a rise rather than a fall in certain cancer rates. As adverse reactions usually occur only with toxicity, assess for these e ects on a periodic basis. It is important also to assess vitamin A intake from all sources, including food and vitamin supplementation, to determine the amount consumed by the individual. In Westernised societies beri-beri-like symptoms occur in individuals with alcohol problems who also consume an inadequate diet. As other vitamins are also lacking, various other symptoms are present apart from those of both dry and wet beri-beri. Prophylaxis with thiamine therapy has been used in conditions such as alcohol misuse, malnutrition, severe malabsorption from intestinal conditions and prolonged fasting as may occur in intensive care units. Clinical considerations iamine malabsorption commonly occurs in people with alcohol problems, cirrhosis or gastrointestinal disease. People who regularly consume more than 60 g of alcohol daily should be considered at risk of developing a thiamine de ciency. It is important to adhere to the recommended dose schedule, as higher doses may not be fully used. Apart from multivitamin preparations, thiamine is available as Betamin, and as vitamin B1. For severe beri-beri, thiamine can be administered intravenously; care should be taken with this mode of administration as anaphylaxis has been reported. Vitamin B1 (thiamine) Anyone who takes multivitamin preparations will be aware of the distinctive smell of some of them. De ciency of thiamine leads to the disease beri-beri, named for the Singhalese word for weakness. When natural rice grains are re ned, the vitamin-bearing part of the grain is removed and a thiamine de ciency can occur. Beri-beri is categorised into two types, depending on whether the de ciency is chronic or acute. In chronic de ciency (or dry beri-beri), the essential feature is a polyneuropathy of the peripheral nerves with a resultant loss in motor control. Vitamin B2 (riboflavin) Ribo avin is so-named because it contains a ribose moiety as part of the molecule and is yellowish in colour (Latin avus, yellow). Individuals using ribo avin supplements should be warned that their urine may be bright yellow. Almonds are a good source and many other plant products contain reasonable amounts. In the body, ribo avin is converted into several di erent coenzymes, the principal ones being avin mononucleotide and avin adenine dinucleotide. Both of these are important in the metabolism of fats, carbohydrates and proteins, being hydrogen carriers from various metabolites into the respiratory chain. A de ciency of ribo avin causes cheilosis (ssures on the lips) and stomatitis (cracks in the angles of the mouth). Ribo avin is sensitive to light, and foodstu s containing this vitamin supplement should be kept out of direct sunlight. Importantly, if catecholamines (adrenaline, dopamine and derivatives) are to be measured in urine, ribo avin in excess might interfere with the analysis. Clinical considerations Ribo avin de ciency usually accompanies de ciencies in other vitamins of the B complex group. Inform the person that the absorption of ribo avin is improved when it is taken with meals and that it may cause bright yellow or orange discoloration of urine. Vitamin B3 (nicotinamide) and nicotinic acid Nicotinamide (also known as niacinamide) and nicotinic acid (also known as niacin), even though chemically slightly di erent, function in a similar way to each other. Large doses of the nicotinic acid form of vitamin B3 have been used to treat hyperlipidaemias.

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