By H. Kapotth. Northwestern Michigan College. 2019.
However discount zenegra 100mg otc erectile dysfunction main causes, in the case of obese children generic 100 mg zenegra amex impotence lifestyle changes, the child may receive an artificially high dose purchase zenegra 100 mg visa erectile dysfunction workup. The reason for this is that fat tissue plays virtually no part in metabolism, and the dose must be estimated on lean or ideal body weight. As a rule of thumb, doses should be reduced by approximately 25% for obese children. Question 8 Dose = 5mcg/kg/min, patient’s weight = 65kg What is the dose in mcg/min? A dose can be described as a single dose, a daily dose, a daily divided dose, a weekly dose or a total dose, etc. If using a 125mg/5mL suspension, it would be appropriate to give this in four divided doses: 512 mg = 20. The easiest way is by proportion: what you do to one side of an equation, do the same to the other side. Also, when what you’ve got and what you want are in different units, you need to convert everything to the same units. When converting to the same units, it is best to convert to whole numbers to avoid decimal points, as fewer mistakes are then made. We have: 50 micrograms in 1 mL So: 100 micrograms in 2 mL (by doubling) It follows: 150 micrograms in 3 mL (1mL + 2mL) From this: 125 micrograms would be within the range 2–3mL. From the above, a formula can be derived to calculate drug dosages: amount you want × volume it’s in amount you’ve got This formula should be familiar as this is the one universally taught for calculating doses. Remember care must be taken when using any formula – ensure that numbers are entered and calculated correctly. From the above example: amount you want = 125 micrograms amount you’ve got = 50 micrograms volume it’s in = 1mL Substitute the numbers in the formula: 125 × 1 = 2. The following case report illustrates the importance of ensuring that your calculations are right. The doctor is reported to have worked out the dose on a piece of paper and then checked it on a calculator but the decimal point was inserted in the wrong place and 15 instead of 0. The dose was then prepared and handed to the senior registrar who administered it without double-checking the calculation and, despite treatment with naloxone, the baby died 55 minutes later. The following two cases illustrate the importance of checking numbers before administration. Although it is still not known whether this dose was chosen deliberately or prescribed in error, there is evidence to support the use of a 2g oral regimen. What concerned the reporting hospital was that the nurse administered 10 × 200mg tablets to the patient without any reference or confirmation that this was indeed what was intended. This use of amiodarone is at present outside the product licence and would not have been described in any of the literature available on the ward. The patient subsequently died, but at the time of writing no causal effect from this high dose of amiodarone had been established. The prescribed dose was misread and two nurses checking each other gave five pre-filled syringes, i. So much heparin was required that another patient’s supply had to be used as well and the error came to light when the ward made a request to pharmacy for 25,000 unit doses of dalteparin. When the error was discovered the patient’s coagulation status was checked immediately and she fortunately came to no harm. Comment It seems inconceivable that such high numbers of dose units could be administered to patients without the nurses involved at least querying that something might be wrong. Question 15 If Oramorph® concentrate 100 mg/5 ml is used to give a dose of 60mg for breakthrough pain, what volume is required? Question 17 You need to give ranitidine liquid at a dose of 2 mg/kg to a 9-year-old child weighing 23kg. Question 18 You need to give a dose of trimethoprim suspension to a child weighing 18. Question 19 Ciclosporin (cyclosporin) has been prescribed to treat a patient with severe rheumatoid arthritis. Ciclosporin (cyclosporine) is available in 10 mg, 25 mg, 50 mg and 100 mg capsules. Question 20 You need to give aciclovir (acyclovir) as an infusion at a dose of 5 mg/kg every 8 hours. Question 21 A 50 kg woman is prescribed aminophylline as an infusion at a dose of 0. Question 22 You need to prepare an infusion of co-trimoxazole at a dose of 120mg/kg/day in four divided doses for a patient weighing 68kg. Displacement values or volumes 91 iii) How many ampoules do you need for 24 hours? If you take ordinary salt and dissolve it in some water, the resultant solution will have a greater volume than before. For example, to make up 100mL of amoxicillin (amoxycillin) suspension, only 68 mL of water needs to be added. However it can be very important when you want to give a dose that is less than the total contents of the vial – a frequent occurrence in paediatrics and neonatology. The volume of the final solution must be considered when calculating the amount to withdraw from the vial. The total volume may be increased significantly and, if this is not taken into account, significant errors in dosage may occur, especially when small doses are involved as with neonates. Thus if the displacement volume is not taken into account, then the amount drawn up is 164mg and not 180mg as required. Displacement values will depend on the medicine, the manufacturer and its strength. Information on a medicine’s displacement value is usually stated in the relevant drug information sheets, in paediatric dosage books, or can be obtained from your Pharmacy Department. Calculating doses using displacement volumes: volume to be added = diluent volume – displacement volume For example, for benzylpenicillin: Dose required = 450mg Displacement volume = 0. You have a 1 g vial that needs to be reconstituted to 10 mL with Water for Injections. You have a 1 g vial that needs to be reconstituted to 4 mL with Water for Injections. You have a 250mg vial that needs to be reconstituted to 5mL with Water for Injections. What are moles and millimoles 95 • A one molar (1 M) solution has one mole of the substance dissolved in each litre of solution (equivalent to 1mmol per mL). These are measurements carried out by chemical pathology and the units used are usually millimoles or micromoles. The millimole unit is also encountered with infusions when electrolytes have been added.
Prolonged or painful stomatitis may contribute to dehydration or may cause loss of appetite with denutrition purchase zenegra paypal erectile dysfunction diabetes viagra, particularly in children discount zenegra online amex impotence for erectile dysfunction causes. In infants generic zenegra 100mg without prescription erectile dysfunction stress treatment, examine routinely the mouth in the event of breast refusal or difficulties in sucking. In all cases: – Maintain adequate hydration and feeding; offer foods that will not irritate the mucosa (soft, non-acidic). Use a nasogastric tube for a few days if pain is preventing the patient from eating. Oral and oropharyngeal candidiasis Infection due to Candida albicans, common in infants, immunocompromised or diabetic patients. Other risk factors include treatment with oral antibiotics or high-dose inhaled corticosteroids. Clinical features White patches on the tongue, inside the cheeks, that may spread to the pharynx. Show the mother how to treat since, in most cases, candidiasis will be treated at home. Primary infection typically occurs in children aged 6 months-5 years and may cause acute gingivostomatitis, sometimes severe. After primary infection, the virus remains in the body and causes in some individuals periodic recurrences which are usually benign (herpes labialis). Local lesions are usually associated with general malaise, regional lymphadenopathy and fever. Both forms of herpes are contagious: do not touch lesions (or wash hands afterwards); avoid oral contact. Other infectious causes See Pharyngitis (Chapter 2), Diphtheria (Chapter 2), Measles (Chapter 8). It is common in contexts of poor food quality or in populations completely dependent on food aid (refugee camps). Other lesions resulting from a nutritional deficiency Other vitamin deficiencies may provoke mouth lesions: angular stomatitis of the lips and glossitis from vitamin B2 (riboflavin), niacin (see Pellagra, Chapter 4) or vitamin B6 (pyridoxine) deficiencies. They must be treated individually or collectively, but must also be considered as indicators of the sanitary condition of a population. A high prevalence of infectious skin diseases may reflect a problem of insufficient water quantity and lack of hygiene in a population. Dermatological examination 4 – Observe the type of lesion: • Macule: flat, non palpable lesion that is different in colour than the surrounding skin • Papule: small (< 1 cm) slightly elevated, circumscribed, solid lesion • Vesicle (< 1 cm), bulla (> 1 cm): clear fluid-filled blisters • Pustule: vesicle containing pus • Nodule: firm, elevated palpable lesion (> 1 cm) that extend into the dermis or subcutaneous tissue • Erosion: loss of the epidermis that heals without leaving a scar • Excoriation: erosion caused by scratching • Ulcer: loss of the epidermis and at least part of the dermis that leaves a scar • Scale: flake of epidermis that detaches from the skin surface • Crust: dried serum, blood, or pus on the skin surface • Atrophy: thinning of the skin • Lichenification: thickening of the skin with accentuation of normal skin markings – Look at the distribution of the lesions over the body; observe their arrangement: isolated, clustered, linear, annular (in a ring). At this stage, primary lesions and specific signs may be masked by secondary infection. In these cases, it is necessary to re-examine the patient, after treating the secondary infection, in order to identify and treat the underlying skin disease. It exists in two forms: ordinary scabies, relatively benign and moderately contagious; and crusted scabies, favoured by immune deficiency, extremely contagious and refractory to conventional treatment. Person to person transmission takes place chiefly through direct skin contact, and sometimes by indirect contact (sharing clothing, bedding). The challenge in management is that it must include simultaneous treatment of both the patient and close contacts, and at the same time, decontamination of clothing and bedding of all persons undergoing treatment, in order to break the transmission cycle. Clinical features Ordinary scabies In older children and adults – Itching, worse at night, very suggestive of scabies if close contacts have the same symptom and – Typical skin lesions: • Scabies burrows (common): fine wavy lines of 5 to 15 mm, corresponding to the tunnels made by the parasite within the skin. Burrows are most often seen in the interdigital spaces of the hand and flexor aspect of the wrist, but may be present on the areolae, buttocks, elbows, axillae. Burrows may be associated with vesicles, corresponding to the entry point of the parasite in the skin. Typical lesions and secondary lesions may co-exist, or specific lesions may be entirely masked by secondary lesions. In infants and young children – Vesicular eruption; often involving palms and soles, back, face, and limbs. Crusted (Norwegian) scabies Thick, scaly, erythematous plaques, generalised or localised, resembling psoriasis, with or without itching (50% of cases). They are washed at ≥ 60°C then dried in the sun, or exposed to sunlight for 72 hours, or sealed in a plastic bag for 72 hours. Ordinary scabies Topical treatment 4 Topical scabicides are applied over the entire body (including the scalp, post-auricular areas, umbilicus, palms and soles), avoiding mucous membranes and face, and the breasts in breastfeeding women. The recommended contact time should not be shortened or exceeded; the patient must not wash his hands while the product is in use (or the product should be reapplied if the hands are washed). In infants, the hands must be wrapped to prevent accidental ingestion of the product. Treatment of secondary bacterial infection, if present, should be initiated 24 to 48 hours before use of topical scabicides (see Impetigo). The preferred treatment is 5% permethrin (lotion or cream): Child > 2 months and adult: one application, with a contact time of 8 hours, then rinse off. Permethrin is easier to use (no dilution required), and preferred over benzyl benzoate in children, and pregnant/lactating women. One application may be sufficient, but a second application 7 days later reduces the risk of treatment failure. A single dose may be sufficient; a second dose 7 days later reduces the risk of treatment failure. Persistence of typical burrows beyond 3 weeks should lead to suspicion of treatment failure (insufficient treatment, e. Crusted scabies Treatment combines simultaneous administration of oral ivermectin and topical scabicide at regular intervals, e. Crusts should be softened (salicylic acid ointment) and removed before applying local treatment (otherwise, local treatment is ineffective). As exfoliated skin scales may spread the parasite, the patient should be isolated during the treatment, staff should use protection (gloves, gowns and hand washing after contact), and environment (bedding, floors and surfaces) should be decontaminated. Body lice are potential vectors of relapsing fever (Chapter 7), typhus (Eruptive rickettsioses, Chapter 7) and trench fever. Treatment Head lice Apply to dry hair 1% permethrin lotion (leave on for 10 min) or 0. Decontaminate combs, headwear and bedding (wash ≥ 60°C/30 min, iron or dry in the sun or, if not feasible, seal in a plastic bag for 2 weeks). Treat those contacts with lice and/or live nits, not those with dead nits alone (dull, white, > 1 cm from scalp) as above. Body lice Mass treatment (outbreakk) Apply 30 to 60 g (2 to 4 heaped soup spoons) of 0. Individual treatment Disinfection of clothing and bedding as above or as for head lice.
As you interview the patient zenegra 100 mg overnight delivery erectile dysfunction specialist, you will come to realize that an organized approach pro- vides a solid foundation zenegra 100 mg for sale pump for erectile dysfunction, but you must follow the patient’s story in the order it is being told versus the patient answering your questions in a predetermined order buy 100 mg zenegra with visa erectile dysfunction mental. This being said, it is necessary to know the core elements of the systematic approach to the patient interview 9 tabLe 1. A conde- Although the words that are spoken scending tone may cause the patient to are important, the tone in which feel as though you are talking “down” they are spoken may influence the to him or her, such that the patient patient’s interpretation of what is may not want to discuss this any fur- being said. Similarly, you may be ther with you, which, in turn, may make able to assess how a patient is feel- you miss an opportunity for smoking ing or reacting based on his or her cessation counseling. A patient may speak ing this in a confident and assertive in a tone that sounds encouraged, tone may cause the patient to at least dejected, sad, excited, angered, or hear what you are saying versus being confused. Choice of The language used may be simple “Detrimental effects on health have been language or complex, clear or confusing, caused by tobacco use. The shown that smoking leads to death, can- meaning of the words may be cer, and hypertension. The following statement is better: “Smoking causes harm to the body, including high blood pressure, cancer, and even death. Facial Many facial expressions are pos- A patient says, “Sometimes, I take my expressions sible: smiling/frowning, looks of mom’s blood pressure medications astonishment, disappointment, when I have a headache because that’s disapproval, surprise, shock, anger, how I know that my pressure’s up. These Upon hearing this, you may feel expressions may happen involun- surprise, shock, and/or disapproval. Although these feelings may be justi- As a patient is speaking, it may be fied, allowing your facial expression to appropriate to smile, which could show these feelings may discourage mean you are encouraging the the patient from divulging information patient to continue speaking, or it to you because of embarrassment and could indicate that you are amused. In contrast, looking perplexed One may also look perplexed, indi- as you ask the patient why he or she cating that either the patient or you thinks a headache means that his or her need more clarity. Body posture Sitting straight or slumped, relaxed If the pharmacist is sitting slumped in and position or tense, and/or with hands a chair, the patient may perceive that crossed over body may indicate there is a lack of interest on the part one’s desire to be a part of the of the practitioner to be present at the conversation or it may reflect feel- patient visit. In addition, the distance or than just continuing to give informa- space between you and the patient tion to the patient, it may be better to may indicate the balance between pause, and ask the patient a reflective respect for personal space and question such as, “What do you think being close enough to comfort- about starting these new medications? Typically, finding a place to sit where you are close enough to reach the patient but not touching the patient is a good distance. If your therefore you should avoid touching patient is moving around too much the patient in the future. Additionally, or acting restless, it may indicate ner- if your patient appears to be moving vousness or discontent. In addition, around too much, you can ask the touching a patient on the shoulder patient a question such as, “You seem may show empathy or go together to be pacing the room—what is on with making a point; however, some your mind? Eye contact If you keep glancing at your As computerized medical records are computer screen or your phone, it becoming more prevalent, if you are appears to the patient that you are reviewing and documenting informa- not interested in what he or she tion as the patient is speaking, it may is saying; however, maintaining make the patient feel as though you continuous eye contact may make are not actively listening. Addi- visit, you can start by telling your tionally, certain cultures consider patient that you will be documenting eye contact to be a sign of respect in the computerized medical record whereas others think it is more throughout the visit to prepare the respectful to not make direct eye patient. Therefore, you should take the patient is answering your ques- nonverbal cues from your patient tions, you should make eye contact to maintain the right amount of and document this information at a eye contact, understanding that a later time. It has been well documented in the medical field that effec- tive communication with patients leads to better diagnosis and treatment, as well as an improved provider–patient relationship. Although most of this research is related to 5 12 chapter 1 / the patient interview physician–patient communications, it can easily translate to communications between the pharmacist and the patient. This is because pharmaceutical care, like the care pro- vided by a physician, involves (1) curing a patient’s disease, (2) eliminating or reducing a patient’s symptoms, (3) arresting or slowing a disease process, and (4) preventing a disease or symptoms. Even though a pharmacist does not make disease diagnoses like 6 physicians do, a pharmacist must nonetheless evaluate the information obtained from the patient interview, including the possibility of certain diagnoses, to appropriately create an assessment and plan, which may include a referral to the patient’s physician or an emergency room for further evaluation. This is typically documented in the patient’s own words and is therefore quoted in the written or oral presentation. One way to deter- mine the patient’s chief complaint is by asking, “What brings you here today? In the case of no overt complaint, the chief complaint may be goal-oriented, such as “I am here to pick up my refills,” “I am here to discuss my labs,” or “My doctor told me to see you about my sugars. For example, a patient may come in complaining of “being out of his furosemide” and, upon evaluation, it may be determined that the patient is experiencing acute heart failure. This assessment and the subsequent plan will be discussed elsewhere in your documentation. History of Present Illness The history of present illness (hpI) is the story of the illness. The pharmacist will 7 further explore the chief complaint as well as any other potential problems by asking questions about any recent or remote history that may be related to the current illness. Seven attributes need to be addressed to obtain a well- characterized description of the complaint or symptom: location, quality, quantity or severity, timing, setting, factors that aggravate or relieve the symptoms, and associated manifestations. For example, if the patient much worse is it now than it is in pain, characterize the pain by using normally is? If “Would you say that this the symptom is pain, ask the patient to swelling is causing your leg to rate the pain on a scale of 1 to 10. Setting This includes addressing the possible “Have you noticed what cause of the symptom. Do you relieve the or nonpharmacologic therapies used to notice a difference in the symptom relieve the symptoms and their efficacy. Are you experienc- that may be a consequence of the primary ing any shortness of breath or symptom. For example, if a patient complains of a cough, it is not necessary to ask about the “location” of the cough. However, if a patient complains of a headache, specifying the exact “location” of the pain (i. A patient who is telling you parts of his or her story may not realize which parts are pertinent. For example, the patient may not know how and what information needs to be relayed to you so that you can make a complete assessment. It is like a puzzle in that you may know what the completed puzzle will look like; however, you have to pick up each piece; examine its shape and color for hints, such as having a flat side, which indicates that it is a border piece; and then place it near other “like” pieces until you are able to fit all the pieces together. You, as the pharmacist, should start thinking of various questions to ask the patient so that the patient’s responses, or the puzzle pieces, may be put together to ascertain or rule out certain assessments. In the case of the patient interview, you will be assessing each piece of information for its reliability, completeness, and relevance to the problem. You may need to assess a patient’s medical condition during the patient interview even if the patient does not have any complaints regarding that medical condition. If the patient has any of the aforementioned symptoms, they would be termed pertinent positives, or the presence of symptoms that are related to the medical the patient interview 15 condition that is being assessed. In contrast, if these symptoms are absent, they would be termed pertinent negatives, or the absence of symptoms related to the medical condition being assessed.
Syphilis order generic zenegra on-line over the counter erectile dysfunction pills uk, other susceptible bacterial Vast experience with use in human infections pregnancy does not suggest teratogenicity cheap zenegra 100 mg visa erectile dysfunction diabetes reversible, other adverse outcomes order zenegra american express erectile dysfunction doctors in atlanta. Bacterial infections tazobactam Limited experience in pregnancy but penicillins generally considered safe. Initial or booster dose for prevention Polysaccharide vaccines generally of invasive pneumococcal infections. Podophyllin, podofilox C Increased embryonic and fetal deaths Because alternative treatments for genital in rats, mice but not teratogenic. Case warts in pregnancy are available, use not reports of maternal, fetal deaths after use recommended; inadvertent use in early of podophyllin resin in pregnancy; no clear pregnancy is not indication for abortion. Posaconazole C Embryotoxic in rabbits; teratogenic in rats at Not recommended similar to human exposures. Risk of growth retardation, low birth weight may be increased with chronic use; monitor for hyperglycemia with use in third trimester. Pyrimethamine C Teratogenic in mice, rats, hamsters (cleft palate, Treatment and secondary prophylaxis neural tube defects, and limb anomalies). Quinidine gluconate C Generally considered safe in pregnancy; high doses Alternate treatment of malaria, control of associated with preterm labor. Quinine sulfate C High doses, often taken as an abortifacient, have Treatment of chloroquine-resistant been associated with birth defects, especially malaria deafness, in humans and animals. Therapeutic doses have not been associated with an increased risk of defects in humans or animals. Ribavirin X Dose-dependent risk of multiple defects Contraindicated in early pregnancy; no (craniofacial, central nervous system, skeletal, clear indications in pregnancy. Report anophthalmia) in rats, mice, hamsters starting at exposures during pregnancy to Ribavirin below human doses. Reports of treatment during Pregnancy Registry at (800) 593-2214 second half of pregnancy in nine women without or www. Sinecatechin C No evidence of teratogenicity in rats and rabbits Not recommended based on lack of ointment after oral or intravaginal dosing. Sulfadiazine B Sulfonamides teratogenic in some animal Secondary prophylaxis of toxoplasmic studies. No clear teratogenicity in humans; encephalitis potential for increased jaundice, kernicterus if used near delivery. Report exposures during pregnancy to Antiretroviral Pregnancy Registry: http:// www. Tenofovir B No evidence of birth defects in rats, Component of fully suppressive rabbits, or monkeys at high doses; chronic antiretroviral regimen in pregnant women. Clinical studies in humans (particularly children) show bone demineralization with chronic use; clinical significance unknown. No evidence of increased birth defects in nearly 2000 first-trimester exposures in women. Used topically so no systemic Topical therapy of non-cervical genital warts bichloracetic acid absorption expected. Minimal Topical agent for treatment of ocular herpes systemic absorption expected with topical infections ocular use. Teratogenic Not recommended in rats (cleft palate, hydronephrosis, and ossification defects). For adults and adolescents with a history of hives-only egg allergy, administer later. Administer a 2-dose series of single antigen hepatitis A vaccine (HepA) at 0 and 6–12 2. Tetanus, diphtheria, and pertussis vaccination months or 0 and 6–18 months, depending on the vaccine, or a 3-dose series of combined Administer 1 dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis hepatitis A and hepatitis B vaccine (HepA-HepB) at 0, 1, and 6 months to adults and vaccine (Tdap) to adults and adolescents who were not previously vaccinated with Tdap, adolescents who may not have a specific risk but wants protection against hepatitis A followed by a tetanus and diphtheria toxoids (Td) booster every 10 years. Administer a HepA-containing vaccine series to adults and adolescents at risk dose of Tdap to women during each pregnancy, preferably in the early part of gestational which includes chronic liver disease, receive clotting factor concentrates, men who have weeks 27–36. Information on the use of Tdap or Td as tetanus prophylaxis in wound sex with men, inject illicit drugs, and travel in countries with endemic hepatitis A. For all sexually active patients, screening should be repeated at least annually and more frequently depending on individual risk or symptoms. Specific sex practices should be avoided that might result in oral exposure to feces (e. Persons who wish to reduce their risk for exposure might consider using dental dams or similar barrier methods for oral- anal and oral-genital contact, changing condoms after anal intercourse, and wearing latex gloves during digital-anal contact. Frequent washing of hands and genitals with warm soapy water during and after activities that might bring these body parts in contact with feces might further reduce risk for illness. Providers should assess a person’s readiness to change this practice and encourage activities to provide education and support directed at recovery. Patients should be counseled to stop using injection drugs and to enter and complete substance abuse treatment, including relapse prevention programs. Day care providers and parents of children in child care are at increased risk for acquiring cytomegalovirus infection, cryptosporidiosis, and other infections (e. The risk for acquiring infection can be diminished by practicing optimal hygienic practices (e. Contact with young farm animals, specifically animals with diarrhea, should be avoided to reduce the risk for cryptosporidiosis. Since soils and sands can be contaminated with Toxoplasma gondii and Cryptosporidium parvum, persons who have extended contact with these materials (e. In areas where histoplasmosis is endemic, patients should avoid activities known to be associated with increased risk (e. In areas where coccidioidomycosis is endemic, when possible, patients should avoid activities associated with increased risk, including extensive exposure to disturbed native soil (e. Because the hygienic and sanitary conditions in pet-breeding facilities, pet stores, and animal shelters vary, patients should be cautious when obtaining pets from these sources. Gloves should always be worn when handling feces or cleaning areas that might have been contaminated by feces from pets. Patients should not allow pets, particularly cats, to lick patients’ open cuts or wounds and should take care to avoid any animal bites. Patients should wash all animal bites, animal scratches, or wounds licked by animals promptly with soap and water and seek medical attention. A course of antimicrobial therapy might be recommended if the wounds are moderate or severe, demonstrate crush injury and edema, involve the bones of a joint, involve a puncture of the skin near a joint, or involve a puncture of a joint directly. Patients who elect to obtain a cat should adopt or purchase an animal aged >1 year and in good health to reduce the risk for cryptosporidiosis, Bartonella infection, salmonellosis, campylobacteriosis, and E. Although declawing is not usually advised, patients should avoid activities that might result in cat scratches or bites to reduce the risk for Bartonella infection. Patients should also wash sites of cat scratches or bites promptly and should not allow cats to lick patients’ open cuts or wounds.
Adults Determine the volume of whole blood to be Example: haemoglobin required = 7 g/dl transfused: patient’s haemoglobin = 4 g/dl V = (haemoglobin required minus patient’s patient’s weight = 60 kg haemoglobin) multiplied by 6 multiplied by Volume in ml = (7 – 4) x 6 x 60 = 1080 ml patient’s weight Determine the transfusion rate: Example: 1080 ml to be administered over 3 hours (1 ml of whole blood = 15 drops) 1080 (ml) ÷ 180 (minutes) = 6 ml/minute 6 (ml) x 15 (drops) = 90 drops/minute Children Newborns and children under 1 year: Example: a malnourished child weighing 25 kg 15 ml/kg over 3 to 4 hours 10 (ml) x 25 (kg) = 250 ml over 3 hours Children over 1 year: 250 (ml) ÷ 180 (minutes) = 1 buy zenegra 100mg low price statistics of erectile dysfunction in us. It is most often caused by both quantitative (number of kilocalories/day) and qualitative (vitamins and minerals order cheap zenegra erectile dysfunction treatment after prostatectomy, etc order zenegra 100 mg line erectile dysfunction treatment pills. Children over 6 months of age The two principal forms of severe malnutrition are: – Marasmus: significant loss of muscle mass and subcutaneous fat, resulting in a skeletal appearance. In addition to these characteristic signs, severe acute malnutrition is accompanied by significant physiopathological disorders (metabolic disturbances, anaemia, compromised immunity, leading to susceptibility to infections often difficult to diagnose, etc. Usual discharge (cure) criteria are: W/H > – 2 Za and absence of bilateral oedema (2 consecutive assessments, one week apart) and absence of acute medical problems. Treatment 1) Nutritional treatment Nutritional treatment is based on the use of therapeutic foods enriched with vitamins and minerals: – Therapeutic milks (for use exclusively in hospitalised patients): • F-75 therapeutic milk, low in protein, sodium and calories (0. Furthermore, it is important to give drinking water, in addition to meals, especially if the ambient temperature is high or the child has a fever. Therapeutic foods facilitate the recovery of gastrointestinal mucosa and restore the production of gastric acid, digestive enzymes and bile. Amoxicillin, administered as part of routine treatment, is effective in reducing bacterial load. Watery diarrhoea is sometimes related to another pathology (otitis, pneumonia, malaria, etc. However, if the child has no profuse diarrhoea, give plain water (not ReSoMal) after each loose stool. The diagnosis is made on the basis of a history of watery diarrhoea of recent onset accompanied by weight loss, corresponding to fluid losses since the onset of diarrhoea. In the event of dehydration: – In there is no hypovolaemic shock, rehydration is made by the oral route (if necessary using a nasogastric tube), with specific oral rehydration solution (ReSoMal) , containing less sodiumd and more potassium than standard solutions. ReSoMal is administered under medical supervision (clinical evaluation and weight every hour). The dose is 20 ml/kg/hour for the first 2 hours, then 10 ml/kg/hour until the weight loss (known or estimated) has been corrected. In practice, it is useful to determine the target weight before starting rehydration. If the child is improving and showing no signs of fluid overload, rehydration is continued until the previous weight is attained. Regardless of the target weight, rehydration should be stopped if signs of fluid overload appear. Bacterial infections Lower respiratory infections, otitis, skin and urinary infections are common, but sometimes difficult to identify (absence of fever and specific symptoms). Severe infection should be suspected in the event of shock, hypothermia or hypoglycaemia. Since the infectious focus may be difficult to determine, a broad spectrum antibiotic therapy (cloxacilline + ceftriaxone) is recommended. Prevention measures include keeping the child close to the mother ’s body (kangaroo method) and provision of blankets. In case of hypothermia, warm the child as above, monitor the temperature, treat hypoglycaemia. Oral candidiasis Look routinely for oral candidiadis as it interferes with feeding; see treatment Chapter 3, Stomatitis. As in children, any malnourished patient presenting with significant complications should initially be hospitalised, regardless of the anthropometric criteria above. Adults: weight gain of 10-15% over admission weight and oedema below Grade 2 and good general condition. Nutritional treatment follows the same principles as in children, but the calorie intake in relation to body weight is lower. Routine treatment is similar to that in children, with the following exceptions: – Measles vaccine is only administered to adolescents (up to age 15). Initially stable and partial obstruction may worsen and develop into a life-threatening emergency, especially in young children. Clinical features Clinical signs of the severity of obstruction: Danger Obstruction Signs signs Complete • Respiratory distress followed by cardiac arrest Imminent • Severe respiratory distress with cyanosis or saturation O2 < 90% complete • Agitation or lethargy • Tachycardia, capillary refill time > 2 seconds Severe • Stridor (abnormal high pitched sound on inspiration) at rest Yes • Severe respiratory distress: – Severe intercostal and subcostal retractions – Nasal flaring – Substernal retractions (inward movement of the breastbone during inspiration) – Severe tachypnoea Moderate • Stridor with agitation • Moderate respiratory distress: – Mild intercostal and subcostal retractions No – Moderate tachypnoea Mild • Cough, hoarse voice, no respiratory distress Management in all cases – Examine children in the position in which they are the most comfortable. Perform maneuvers to relieve obstruction only if the patient cannot speak or cough or emit any sound: – Children over 1 year and adults: Heimlich manoeuvre: stand behind the patient. Place a closed fist in the pit of the stomach, above the navel and below the ribs. Place the other hand over fist and press hard into the abdomen with a quick, upward thrust. Perform one to five abdominal thrusts in order to compress the lungs from the below and dislodge the foreign body. With the heel of the other hand, perform one to five slaps on the back, between shoulder plates. Perform five forceful sternal compressions as in cardiopulmonary resuscitation: use 2 or 3 fingers in the center of the chest just below the nipples. Repeat until the foreign body is expelled and the patient resumes spontaneous breathing (coughing, crying, talking). If the patient loses consciousness ventilate and perform cardiopulmonary rescucitation. Differential diagnosis and management of airway obstructions of infectious origin Timing of Infections Symptoms Appearance symptoms Viral croup Stridor, cough and moderate Prefers to sit Progressive respiratory difficulty Epiglottitis Stridor, high fever and severe Prefers to sit, drooling Rapid respiratory distress (cannot swallow their own saliva) Bacterial Stridor, fever, purulent secretions Prefers to lie flat Progressive tracheitis and severe respiratory distress Retropharyngeal Fever, sore throat and painful Prefers to sit, drooling Progressive or tonsillar swallowing, earache, trismus abscess and hot potato voice – Croup, epiglottitis, and tracheitis: see Other upper respiratory tract infections. Management of other causes – Anaphylactic reaction (Quincke’s oedema): see Anaphylactic shock (Chapter 1) – Burns to the face or neck, smoke inhalation with airway oedema: see Burns (Chapter 10). Clinical features – Nasal discharge or obstruction, which may be accompanied by sore throat, fever, cough, lacrimation, and diarrhoea in infants. Treatment – Antibiotic treatment is not recommended: it does not promote recovery nor prevent complications. Most acute sinus infections are viral and resolve spontaneously in less than 10 days. Acute bacterial sinusitis may be a primary infection, a complication of viral sinusitis or of dental origin. The principal causative organisms are Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus. It is essential to distinguish between bacterial sinusitis and common rhinopharyngitis (see Rhinitis and rhinopharyngitis). Without treatment, severe sinusitis in children may cause serious complications due to the spread of infection to the neighbouring bony structures, orbits or the meninges. Clinical features Sinusitis in adults – Purulent unilateral or bilateral discharge, nasal obstruction and – Facial unilateral or bilateral pain that increases when bending over; painful pressure in maxillary area or behind the forehead. Sinusitis is likely if symptoms persist for longer than 10 to 14 days or worsen after 5 to 7 days or are severe (severe pain, high fever, deterioration of the general condition).