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Each catecholamine Figure 8-2 order naltrexone no prescription medicine 44-527, the indirect-acting agonists increase the stimu- consists of the catechol moiety and an ethylamine side lation of adrenoceptors by increasing the concentration of chain (Fig buy naltrexone with mastercard symptoms 8dpiui. For this reason cheap naltrexone 50mg on line medications emts can administer, these drugs have sympathetic neuron and thereby decreases the neuronal low oral bioavailabilities and short plasma half-lives order 50mg naltrexone overnight delivery treatment for uti, and reuptake of norepinephrine and increases its synaptic they must be administered parenterally when a systemic concentration. Amphetamine and related drugs are trans- action is required (such as in the treatment of anaphylactic ported into the sympathetic nerve terminal by the catechol- shock). As shown in Figure 8-3 and amphetamines inhibit the storage of norepinephrine by Table 8-2, the various catecholamines differ in their affni- neuronal vesicles. The size of the alkyl tion of norepinephrine, leading to reverse transport of substitution on the amine nitrogen (R2) determines the rela- norepinephrine into the synapse by the catecholamine trans- tive affnity for α- and β-adrenoceptors. Epinephrine is a potent agonist at all α- and Direct-Acting Adrenoceptor Agonists β-adrenoceptors. Norepinephrine differs from epinephrine The direct-acting agonists include several catecholamines only in that it has greater affnity for β1-adrenoceptors than and various noncatecholamine drugs. Because of this difference, norepi- nephrine constricts all blood vessels, whereas epinephrine Catecholamines constricts some blood vessels but dilates others. Isoproter- The naturally occurring catecholamines include norepi- enol is a selective β1- and β2-adrenoceptor agonist because nephrine, an endogenous sympathetic neurotransmitter; it has little affnity for α-receptors. Dobutamine primarily epinephrine, the principal hormone of the adrenal medulla; stimulates β1-receptors, with smaller effects on β2- and and dopamine, a neurotransmitter and the precursor to α-receptors. Lower doses of epinephrine produce greater stimula- tion of β2-receptors than α1-receptors, especially in the vascular beds of skeletal muscle, thereby causing vasodilation Catechol Ethylamine and decreasing diastolic blood pressure. It usually lowers the diastolic and mean arterial pressure, but it can R1 R2 increase the systolic pressure by increasing the heart rate and contractility. In patients with heart failure, this effect contributes to an increased Isoproterenol stroke volume and cardiac output (see Chapter 12). At slightly 3 higher doses, dopamine activates β1-adrenoceptors in the heart, thereby stimulating cardiac contractility and increas- Dopamine H H ing cardiac output and tissue perfusion. At even higher (D1 > β1 > α) doses, dopamine activates α1-adrenoceptors and causes vasoconstriction. Catecholamines can cause excessive vaso- constriction, leading to tissue ischemia and necrosis. The amine intravenous drug infusion or from the accidental injection nitrogen substitution (R2) determines the relative affnity for α- and of epinephrine into a fnger, such as when a patient is β-adrenoceptors, with larger substitutions (e. Note that dopamine has an even higher affnity for dopamine D receptors than for adrenoceptors. For this reason, dopamine is both a can cause hyperglycemia secondary to glycogenolysis, and direct-acting and an indirect-acting receptor agonist. Figure 8-4 compares the cardiovas- cular effects when norepinephrine, epinephrine, isoprotere- Specifc Drugs nol, and dopamine are given by intravenous infusion. The cardiovascular effects of norepinephrine primarily Shock is a condition in which the circulation to vital organs result from activation of α1-adrenoceptors. Activation is profoundly reduced as a result of inadequate blood produces vasoconstriction and increases peripheral resis- volume (hypovolemic shock), inadequate cardiac function tance, which in turn increases the systolic and diastolic blood (cardiogenic shock), or inadequate vasomotor tone (neu- pressure. Septic shock is associated blood pressure increases suffciently to activate the barore- with massive vasodilation secondary to the production of ceptor refex. It is sometimes called Epinephrine increases the systolic blood pressure but can “warm shock” to distinguish it from hypovolemic and increase or decrease the diastolic blood pressure. The increased cardiogenic shock, in which the patient’s extremities are systolic pressure results partly from an increased heart rate usually cold because of inadequate blood fow. The effect on diastolic pressure depends of septic shock, however, may also cause hypoperfusion on the relative stimulation of α1- and β2-adrenoceptors, and cold extremities. Norepinephrine, which is a potent vasoconstrictor, is Catecholamine drugs that increase blood pressure are used to treat septic shock and is often given to persons with called vasopressors. These drugs are used in treating shock cardiogenic shock when the response to dopamine is inad- when organ function is impaired because mean arterial equate or is accompanied by marked tachycardia. Hypovolemia should nephrine is also used to treat hypotension caused by decreased always be corrected by intravenous fuid administration peripheral resistance such as can occur in persons who have before the use of vasopressors, because vasopressors will not received excessive doses of a vasodilator drug. In cases of cardiogenic rine is also used for this purpose, as described later in this shock, mechanical devices (e. By producing bronchodilation and increas- performance while reducing myocardial ischemia and cardiac ing blood pressure, epinephrine counteracts the effects of work. Such devices are often used in conjunction with vaso- histamine and other mediators that are released from mast pressor drugs in the treatment of this condition. Epinephrine is used as a vasoconstrictor to reduce when patients remain hypotensive despite adequate fuid bleeding during surgery and to prolong the action of local administration. Dopamine is usually started at a dose of anesthetics by retarding their absorption into the general 2 mg/kg body weight per minute, and then the dose is circulation. Epinephrine is also used as a cardiac stimulant titrated to achieve the desired blood pressure. Although low in the treatment of cardiac arrest and ventricular fbrilla- doses of dopamine can increase urine output by augmenting tion. Isoproterenol is used to treat refractory bradycardia renal blood fow in normal subjects, ample evidence indi- and atrioventricular block when other measures have not cates that low doses of dopamine are usually not effective in been successful. Although it has been used to treat asthma, preventing and treating acute renal failure. The most effec- a selective β2-adrenoceptor agonist is usually preferred for tive means of protecting the kidneys in patients with shock this indication because it does not increase the heart rate as appears to be the maintenance of mean arterial pressure of much as isoproterenol. Comparison of the cardiovascular effects of four catecholamines when a low dose of each drug is given by intravenous infusion. The blood pressure recordings show systolic, diastolic, and mean arterial pressure. Peripheral resistance is expressed on an arbitrary scale, ranging from 0 to 4 units. The refex mechanism, adrenoceptors (α1, β1, and β2), or dopamine (D1) receptors responsible for changes in the heart rate and peripheral resistance are illustrated. Norepinephrine increases peripheral resistance and blood pressure, and this leads to refex bradycardia. Epinephrine increases heart rate while reducing peripheral resistance, and the mean arterial blood pressure increases slightly. Isoproterenol increases heart rate but signifcantly lowers peripheral resistance, and the mean arterial pressure declines. Dopamine increases heart rate (and increases cardiac output) while lowering vascular resistance, and the mean arterial pressure increases. Stings in the oropharyn- developed edema of the face, lips, eyelids, tongue, and geal area have a greater potential to cause airway obstruc- throat and experienced breathing diffculties. Paramedics tion and may require intubation and more aggressive administered subcutaneous epinephrine and transported the treatment than stings in other areas of the body. Hypersen- patient to the hospital, where he received intravenous dexa- sitivity reactions are mediated by immunoglobulin E, which methasone (a corticosteroid). The child previously had an cross-links antigens on mast cells and basophils, leading to allergic reaction to a bee sting that did not require hospital- the release of histamine and other chemical mediators that ization. Because of his respiratory distress, he was intubated cause edema and laryngospasm.
The drug is effective but can cause multiple adverse effects generic naltrexone 50 mg without prescription medications qt prolongation, and dosing is difficult generic naltrexone 50mg with visa treatment 1st metatarsal fracture. To ensure therapeutic effects and minimize toxicity buy naltrexone 50 mg on line symptoms hypoglycemia, blood levels of lithium must be monitored; the target range is 0 naltrexone 50 mg visa medicine cabinet shelves. With all of these drugs, prophylactic therapy should be limited to the cluster cycle and then discontinued when the current cycle is over. Treatment If an attack occurs despite preventive therapy, it can be aborted with sumatriptan or oxygen. Inhaling 100% oxygen (7 to 10 L/min for 15 to 20 minutes) is also highly effective and has virtually no adverse effects. However, their use today is limited because modern trials are small in population and lack evidence that these drugs work any better at relieving cluster headaches than placebo. Tension-Type Headache Characteristics Tension-type headaches are the most common headache type. These headaches are characterized by moderate, nonthrobbing pain, usually located in a “headband” distribution. Headache is often associated with scalp tingling and a sense of tightness or pressure in the head and neck. Depressive symptoms (sleep disturbances, including early and frequent awakening) are often present. By definition, chronic tension-type headaches occur 15 or more days per month for at least 6 months. Treatment An acute attack of mild to moderate intensity can be relieved with a nonopioid analgesic: acetaminophen or a nonsteroidal antiinflammatory drug (e. However, because of their potential for dependence and abuse, these combinations should be reserved for acute therapy of episodic attacks; they are inappropriate for patients with chronic daily headaches. For prophylaxis, amitriptyline [Elavil], a tricyclic antidepressant, is the drug of choice. Dosing at bedtime will help relieve any depression-related sleep disturbances in addition to protecting against headache. Instruction should include cognitive coping skills and information on relaxation techniques (e. With triptans, withdrawal headaches are relatively mild and often resolve in a few days. In contrast, with analgesics or ergots, withdrawal headaches are more intense and may persist for 2 weeks or more. If possible, patients should take these drugs no more than 2 or 3 times a week—and doses should be no higher than actually needed. Alternating headache medicines may help, too, because this would limit exposure to any one drug. If headaches begin to occur more than 2 or 3 times a month, prophylactic therapy should be tried. U N I T V I I Psychotherapeutic Drugs O U T L I N E Chapter 24 Antipsychotic Agents and Their Use in Schizophrenia Chapter 25 Antidepressants Chapter 26 Drugs for Bipolar Disorder Chapter 27 Sedative-Hypnotic Drugs Chapter 28 Management of Anxiety Disorders Chapter 29 Central Nervous System Stimulants and Attention- Deficit/Hyperactivity Disorder C H A P T E R 2 4 Antipsychotic Agents and Their Use in Schizophrenia Laura D. Specific indications include schizophrenia, delusional disorders, bipolar disorder, depressive psychoses, and drug-induced psychoses. As a rule, antipsychotics should not be used to treat dementia-related psychosis in older adults, owing to a risk for increased mortality. Since their introduction in the early 1950s, the antipsychotic agents have catalyzed revolutionary change in the management of psychotic illnesses. Before these drugs were available, psychoses were largely untreatable and patients were fated to a life of institutionalization. With the advent of antipsychotic medications, many patients with schizophrenia and other severe psychotic disorders have been able to leave psychiatric hospitals and return to the community. For those who must be institutionalized, antipsychotic drugs have at least reduced suffering. Schizophrenia: Clinical Presentation and Etiology Clinical Presentation Schizophrenia is a chronic psychotic illness characterized by disordered thinking and a reduced ability to comprehend reality. P ro t o t y p e D r u g s Antipsychotic Agents Traditional Antipsychotics Chlorpromazine (a low-potency agent) Haloperidol (a high-potency agent) Atypical Antipsychotic Clozapine Three Types of Symptoms Symptoms of schizophrenia can be divided into three groups: positive symptoms, negative symptoms, and cognitive symptoms. Positive symptoms include hallucinations, delusions, agitation, tension, and paranoia. Negative symptoms include lack of motivation, poverty of speech, blunted affect, poor self-care, and social withdrawal. Cognitive Symptoms Cognitive symptoms include disordered thinking, reduced ability to focus attention, and prominent learning and memory difficulties. Subtle changes may appear years before symptoms become florid, when thinking and speech may be completely incomprehensible to others. Acute Episodes During an acute schizophrenic episode, delusions (fixed false beliefs) and hallucinations are frequently prominent. Disordered thinking and loose association may render rational conversation impossible. These include suspiciousness, poor anxiety management, and diminished judgment, insight, motivation, and capacity for self-care. As a result, patients frequently find it difficult to establish close relationships, maintain employment, and function independently in society. Inability to appreciate the need for continued drug therapy may cause nonadherence, resulting in relapse and perhaps hospital readmission. Long-Term Course The long-term course of schizophrenia is characterized by episodic acute exacerbations separated by intervals of partial remission. As the years pass, some patients experience progressive decline in mental status and social functioning. Maintenance therapy with antipsychotic drugs reduces the risk for acute relapse but may fail to prevent long-term deterioration. Etiology Although there is strong evidence that schizophrenia has a biologic basis, the exact etiology is unknown. Genetic, perinatal, neurodevelopmental, and neuroanatomic factors may all be involved. Although psychosocial stressors can precipitate acute exacerbations in susceptible patients, they are not considered causative. Accordingly, it seems appropriate to begin with these drugs, even though their use has greatly declined. Classification by Potency First-generation antipsychotics can be classified as low potency, medium potency, or high potency (Table 24. The low-potency drugs, represented by chlorpromazine, and the high-potency drugs, represented by haloperidol, are of particular interest. The incidence of late reactions (tardive dyskinesia) is the same for all traditional antipsychotics. Recall that the term potency refers only to the size of the dose needed to elicit a given response; potency implies nothing about the maximal effect a drug can produce. Hence, when we say that haloperidol is more potent than chlorpromazine, we only mean that the dose of haloperidol required to relieve psychotic symptoms is smaller than the required dose of chlorpromazine.
The aforementioned symptoms associated with hypercalcaemia and nephrocalcinosis indicate hyperparathyroidism generic naltrexone 50mg online treatment 4 sore throat. It may be primary (as a result of adenoma generic naltrexone 50 mg with mastercard medicine ball exercises, hyperplasia or carcinoma of the parathyroid) buy online naltrexone medicine cabinet home depot, secondary (chronic renal failure best order for naltrexone medications medicaid covers, malabsorption, rickets or osteomalacia) or tertiary (autonomous from secondary). The clinical details given in the stem usually contain the information that you need to separate the correct option from the distracter(s). Double check the question again to make sure you haven’t missed a subtle fact and that you’ve interpreted the situation correctly. You will need some knowledge of the psychology of parenting (clinical knowledge gained from reading textbooks) and you will need to be aware of child protection issues and safety concerns (ethics and law). Applying your skills/experience, knowledge, and attitudes you can correctly select the answer E – ignore the child until it stops screaming – which will ensure that you fnish your shopping and avoid child protection services. Each option may be used more than once or not at all, that is, it is possible that one of the options could be the correct answer for two of the questions. If the list of options looks a bit unusual, the reason for this is that the committee writes many more questions to go with each option list so that there is a large bank of questions available looking at various aspects of a clinical scenario. An unusual option may belong to another question on the bank, so don’t fall into the trap of assuming that because it’s an unusual option that you hadn’t thought of, then it must be the correct answer. Remove the child to a safe place These options initially all look plausible and very similar, however if you refect on your reading of parenting manuals (textbooks) you will recall that bribing with sweets will set up a vicious cycle resulting in worsening behaviour, and your experience tells you that a toddler in a full-blown tantrum is not distract- ible. Leaving the store rewards bad behaviour, and if you review carefully the scenario it’s hard to imagine a supermarket as being a particularly dangerous place (experience) unless you ‘overthink’ the question and imagine the child to be next to an unstable display of baked bean cans or something similar. The message here is: carefully assess the information given but don’t read complexity into the scenario where there is none. In the actual examination, you can use the question booklet to write on and make notes (as it is not read when it is returned to the College), but you must transfer your answers to the computer-marked sheet before the examination fnishes. The risk of leaving gaps on the answer sheet as you progress through the examination is that you might incorrectly transcribe your answers and lose marks when your answers were originally correct. You are supplied with an eraser to make corrections, and you must be very careful when you’ve fnally chosen your answers to make sure that you complete the answer sheet correctly. The examiners try hard to avoid predictable patterns when selecting the ques- tions. Great care is also taken to avoid questions that have ‘always’ or ‘never’ as these are obviously incorrect given the nature of clinical medicine. If a question looks like an ‘always or never’ scenario, re-read it as you may have missed a crucial part of the question. These facts are unlikely to be the topic of your ward rounds, handovers, or refective practice sessions so it really does pay to revise. Each examination diet is blueprinted to ensure that all areas of the syllabus are covered, so the best advice is to ensure that you have covered the whole syl- labus in your reading and revision, rather than trying to ‘spot’ questions. In addition to the textbooks you used as an undergraduate, there are sev- eral books on the market covering issues relevant to women’s health in general practice, and we suggest that you also access specifc texts on contraception and genitourinary medicine. We have provided a list of websites where you will fnd helpful information about some topics that could come up in the examina- tion, and although this list is not exhaustive, we think you will fnd that the websites contain interesting revision material. Doing exam questions is a very good way to revise, and it is highly recom- mended that you re-read a topic where your score is disappointing – you will be even more disappointed if it comes up in the examination and you have neglected to revisit that topic and top up your knowledge. Whilst you are revising, don’t forget to eat, sleep, and relax too – all these things will improve your performance! To pass the exam reading and revision is required, but understanding the style of questions and practising questions will improve your chance of success. Learning Outcomes This module covers history taking; clinical examination and investigation; note keeping; legal issues relating to medical certifcation; time management and decision making; communication; and ethics and legal issues. It is easy to set clinical questions on history, examination, or investigation, but quite a challenge to set written questions to test the other areas. We have also tried to look at attitudes and behaviour using written ques- tions concentrating on issues such as consent, domestic violence, and con- fdentiality. When tak- ing a history, which of the following symptoms suggests that the diagnosis might be endometriosis? There is a linear burn across the patient’s abdomen that occurred during ironing E. The woman seems unsure about her request for termination of unwanted pregnancy Answer [ ] 1. When they suffer an early pregnancy complication, which one of these non- sensitised, rhesus negative women does not need anti-D immunoglobulin? Miscarriage less than 12 weeks when the uterus is evacuated surgically or medically B. Every maternal death in the United Kingdom is scrutinised to look for substandard care B. Reducing the number of maternal deaths worldwide by the year 2050 is a ‘millennium development goal’ C. The maternal mortality rate is lower in the United States than in the United Kingdom D. The maternal mortality ratio is defned as the number of maternal deaths per hundred thousand pregnancies E. She is healthy with no other medical problems and is using the withdrawal method for contraception. Which of the following statements is correct regarding Ebola infection in pregnancy? The fetus is likely to survive if delivered now because she is in the third trimester D. Site an intravenous infusion for a severely dehydrated patient with hyperemesis B. Review a woman who has just miscarried an 18-week fetus but not deliv- ered the placenta E. Her booking blood pressure in the ﬁrst trimester was 130/88 mmHg but it is now 160/95 mmHg, and the midwife has checked the blood pressure twice. On examination you ﬁnd thickening of both labia minora with a couple of shal- low ulcers on both sides and a split area at the fourchette. On examination severe lower abdominal tenderness with gen- eralised guarding and rebound, also foetor oris. Pelvic examination reveals no tenderness but uterus is small for dates and the cervical os is closed. Transvaginal ultrasound scan shows an intrauterine sac with a fetal pole but no heart pulsation detected. Last menstrual period was 2 weeks ago and on examination has a tender abdomen with guarding. Her cycles are still regular with a cycle of 26 days but the bleeding is now very heavy with clots. The uterus is enlarged to the size of an orange, smooth, and very tender but mobile with no adnexal tenderness. She works long hours as a computer programmer and smokes ﬁfteen ciga- rettes a day. Which of the following factors is the most likely cause of her recurrent miscarriages?