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HEART MURMURS AND EXTRA HEART SOUNDS Table 1–2 and Figure 1–1 describe the various types of heart murmurs and extra heart sounds 100mg kamagra chewable overnight delivery impotence reasons and treatment. BLOOD PRESSURE GUIDELINES There is a clear association between hypertension and coronary artery and cerebrovascular disease quality 100mg kamagra chewable doctor who cures erectile dysfunction. Hypertension is defined as systolic BP >140 mm Hg or a diastolic BP >90 mm Hg in adults. Use the bell of the stethoscope, the last sounds heard are the Korotkoff sounds, which are low- pitched. Elevated readings on three separate days should be obtained prior to diagnosing hypertension. Many times, the patient may have some intraoral problem that is contributing to the overall medical con- dition (ie, the inability to eat due to a toothache, abscess, or ill-fitting denture in a poorly controlled diabetic) for which a dental consult may be necessary. In addition, in an emergency situa- tion when intubation is necessary, complications may occur if the clinician is unfamiliar with the oral structures. The patient may be able to give some dental history, including recent toothaches, ab- scesses, and loose teeth or dentures. Be sure to ask if the patient is wearing a removable par- tial denture (partial plate), which should be removed before intubation. As lost dentures are a chief dental complaint of hospitalized patients, care must be taken not to misplace the re- moved prosthesis. A brief dental examination may be performed with gloved hand, two tongue blades, and a flashlight. Look for any obvious inflammation, erythema, edema, or ulceration of the gin- giva (gums) and oral mucosa. Place each tooth between two tongue blades and push gently to check for looseness. This is espe- cially important for the maxillary anterior teeth, which serve as the fulcrum for the laryngo- scope blade. Any abnormal dental findings should be noted and the appropriate consults obtained. Many diseases, including AIDS, STDs, pemphigus, pemphigoid, allergies, uncon- trolled diabetes, leukemia, and others, may first manifest themselves in the mouth. Patients who will be receiving head and neck radiation must be examined and treated for any tooth extractions or dental infections before the initiation of the radiation therapy. Extractions after radiation to the maxilla and particularly the mandible may lead to osteoradionecrosis, a condition that may be impossi- ble to control. Sys- tolic (medium-pitched) crescendo–de- crescendo murmur with radiation to the carotid arteries. Narrow pulse pressure and delayed carotid upstroke and left ventricular hypertrophy (LVH) with lift at apex. Aortic insufficiency (AI) Heard best at left lower sternal border third and fourth interspace with patient sitting up, leaning forward and fully exhaled. Diastolic (low-pitched rumbling sound) murmur heard best with the bell in the left lateral decubitus position. Patent ductus Heard best at left first and second intercostal arteriosus (PDA) space. Third heard sound (S3) Early diastolic sound caused by rapid ventric- ular filling. Left-sided S3 seen nor- mally in young people, also pregnancy, thy- rotoxicosis, mitral regurgitation, and congestive heart failure. Fourth heart sound (S4) Late diastolic sound caused by a noncompli- ant ventricle. Often, parents think some- thing is developmentally wrong with their child if teeth have not appeared by a certain age. Factors contributing to this variation in- clude family history, ethnic background, vitality during fetal development, position of teeth in the arch, size and shape of the dental arch itself, and, in the case of the eruption of perma- nent teeth, when the primary tooth was lost. Radiographs of the maxilla and mandible can determine whether or not the teeth are present. Ex- amples: Aging, striae associated with obesity, scleroderma Bulla: A superficial, well-circumscribed, raised, fluid-filled lesion greater than 1 cm in diameter. Examples: Bullous pemphigoid, pemphigus, dermatitis herpetiformis Burrow:A subcutaneous linear track made by a parasite.

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The net ample order kamagra chewable 100mg fast delivery erectile dysfunction meds at gnc, inhalational anesthetics used in combination change of anesthetic tension becomes smaller with each breathing cycle discount 100mg kamagra chewable otc erectile dysfunction relationship, and the curve of alveolar tension will approach the inspired level more slowly. The alveolar tension–time curve always declines in Minimum Alveolar an exponential manner, but the position of the curve TABLE 25. Desflurane Sevoflurane To illustrate the effect of solubility on the rate of in- Methoxyflurane duction of anesthesia, we can consider a situation in which individual agents are delivered to patients at their equivalent MAC values. Under these conditions, regardless of the agent being employed, a similar level 3 60 120 of anesthesia will be achieved. In contrast, induction Time (min) rates, illustrated as the time required for the alveolar tension to rise to the inspired level (Fig. However, halothane, enflurane, and isoflurane, which have significant blood and tissue solu- anesthesia, that is, after patients become unconscious. Methoxyflurane, a highly solu- ecules, blood returning to the lung will have increas- ble agent, requires several hours and may be clinically ingly high anesthetic tension, and the alveolar–arterial impractical if administered in this way. Since the gradient controls the rate of diffusion across the alveolar capil- Effect of Pulmonary Perfusion lary membrane, uptake is also reduced and the rate of rise of the alveolar tension of anesthetic is accelerated. The rate of pulmonary perfusion (in healthy individuals, essentially equivalent to the cardiac output) also affects Effect of Solubility of Various Agents the rate of induction of anesthesia. Since more blood will pass through the pulmonary capillary bed when the The inhalational anesthetics have distinctly different cardiac output is high, it follows that a greater total solubility (affinity) characteristics in blood as well as in transfer of any anesthetic agent across the alveolus will other tissues. These solubility differences are usually expressed as coefficients and indicate the number of volumes of a particular agent distributed in one phase, as compared with another, when the partial pressure is at equilibrium (Table 25. Thus, when the partial pressure has reached equi- Anesthetic Gas Blood/Gas Tissue/Blood librium, blood will contain 1. Also, tissues normally receiv- Ventilation (VA) ing a smaller proportion of the total cardiac output re- 8 ceive a greater amount when cardiac output is high and 100 4 will accumulate a larger proportion of the anesthetic 2 crossing the alveolar membrane. Ultimately, greater up- 90 take will slow the rate of rise of the alveolar tension– 80 time curve, and anesthetic induction with an individual agent may be slower when the cardiac output and per- 70 8 fusion of the lung are high. The rate of uptake will be lower, and 4 the alveolar tension will rise toward the inspired tension 50 more quickly. To minimize the effect of cardiac output on the rate of induction of anesthesia, agents of lower 40 2 solubility would be preferred clinically. A useful technique to increase the input of anes- from 2 to 4 and from 4 to 8 liters per minute (constant thetic to the lung is to elevate the minute alveolar ven- cardiac output). This maneuver, which causes a greater quantity soluble agent, halothane, and smaller with the least soluble of fresh anesthetic gas to be delivered to the patient per anesthetic, nitrous oxide. This maneuver, frequently re- tensions of anesthetics are used, particularly if they are ferred to as overpressure, parallels the concept of load- highly soluble, a large uptake from the alveoli will oc- ing dose. Consequently, the lung volume may tend to shrink, alveolar tension is achieved, the delivered tension of causing negative pressure. However, the shrinkage is anesthetic must be returned to the maintenance (MAC) opposed by the pulling in of fresh gases from nonrespi- level to avoid overdosing the patient. Other Factors Affecting the Alveolar Tension Since greater uptake will occur with 75% N2O than with of Anesthetic Agents 40%, the effect will be greater at higher inspired anes- Special factors influence the rate of rise of the alveolar thetic tensions. These factors particularly Second Gas Effect significant when N2O is used, since it is often required in The alveolar tension of other anesthetic gases also concentrations exceeding 25% in the inspired air. Concentration Effect These gases are also subject to the increased inflow When anesthetics are delivered in high concentra- (pulling in of fresh gases) as N2O is taken up into the tion, the alveolar tension will rise rapidly. N2O is being delivered in the inspired air, the 75% ten- sion in blood will be established more quickly than if Diffusion Hypoxia 40% N2O were being inhaled and a 40% N2O tension Diffusion hypoxia may be encountered at the end of were desired in blood. The mechanism 25 General Anesthesia: Intravenous and Inhalational Agents 303 underlying diffusion hypoxia is essentially the reverse blockade provided by the halogenated hydrocarbons is of the concentration effect; that is, when anesthetic ad- incomplete, neuromuscular blocking agents, such as suc- ministration is stopped, large volumes of N2O move cinylcholine or the curariform drugs, must be used to from the blood into the alveolus, diluting oxygen and provide paralysis adequate for surgical access. To avoid diffusion the anesthetic plan is also designed to minimize any un- hypoxia, the anesthesiologist may employ 100% oxygen desirable cardiovascular and respiratory responses to rather than room air after discontinuing administration these drugs. For example, N2O 25 to 40%, which by itself produces mini- Halogenated Hydrocarbon Anesthetics mal cardiovascular depression, is frequently used with about half of the MAC of a particular halogenated hy- Sevoflurane, desflurane, enflurane, isoflurane, halothane, drocarbon; this tends to preserve cardiovascular stabil- and methoxyflurane are considered to be quite potent ity. Since MACs are additive, unconsciousness is ade- halogenated hydrocarbon anesthetics, since they pro- quate when a combination of inhalational agents is used. None of the halogenated hydrocarbons, how- ever, possess all of the pharmacological properties that Halothane are considered desirable for an anesthetic agent, so they Halothane (Fluothane) depresses respiratory function, are often given with other anesthetics and adjunctive leading to decreased tidal volume and an increased rate drugs to provide effective and safe anesthetic manage- of ventilation. The use of these drug combinations is referred to quately compensate for the decrease in tidal volume, as balanced anesthesia.

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This preparation should not be used if a has central nervous system depression or has ingested bowel obstruction or impaired gag reflex is present discount kamagra chewable 100mg without a prescription erectile dysfunction pills names. It acts directly on the CTZ and also indirectly by irritating PHARMACOLOGICAL MODULATION the gastric mucosa 100 mg kamagra chewable free shipping impotence gel. Ipecac is cardiotoxic if absorbed and OF VOMITING can cause cardiac conduction disturbances, atrial fibril- Vomiting is a complex series of integrated events culmi- lation, or fatal myocarditis. If emesis does not occur, nating in the forceful expulsion of gastric contents gastric lavage using a nasogastric tube must be per- through the mouth. Duodenal and jejunal tone is increased, while gastric first administered before oral or subcutaneous dosing. Opioid antagonists such as nalox- lows nausea, during which the abdominal muscles con- one usually reverse the depressant actions of apomor- tract with simultaneous attempts at inspiration against a phine. During vom- iting, which is the third and final stage, there is sustained Antiemetics contraction of the diaphragm and abdominal muscula- Antiemetics may prevent emesis by blocking the CTZ ture. The resultant high intragastric pressure moves more or by preventing peripheral or cortical stimulation of gastric contents into the esophagus, and with continued the emetic center. These events are coordinated by the emetic center, Antihistamines which lies within the lateral reticular formation of the medulla oblongata close to the respiratory and salivary The antihistamines appear to block peripheral stimula- centers. They are therefore most ef- 40 Drugs Used in Gastrointestinal Disorders 477 fective in motion sickness and inner ear dysfunction, at the CTZ by inhibiting dopaminergic transmission. Dimenhydrinate, diphenhy- suggesting that they inhibit stimulation of peripheral dramine, and meclizine hydrochloride are the three an- vagal and sympathetic afferents. Sedation will fre- tihistamines primarily used in the prevention of nausea quently occur following their administration. A more complete discussion also may have problems with acute dystonic reactions, of the H1antihistamines can be found in Chapter 38. Anticholinergics 5-HT3 Receptor Antagonists The transdermal adhesive form of scopolamine (Trans- derm Scop) provides up to 72 hours of antiemetic pro- Ondansetron (Zofran) and granisetron (Kytril) are po- tection when applied to the postauricular area. Side ef- tent antagonists of 5-HT3 receptors, which are found pe- fects are similar to those of oral scopolamine (see ripherally on vagal nerve terminals and centrally in the Chapter 13) but milder. During chemotherapy that induces vomiting, mu- cosal enterochromaffin cells in the GI tract release sero- Benzodiazepines tonin, which stimulates 5-HT3 receptors. In binding to Benzodiazepines and their congeners may help prevent 5-HT3 receptors, ondansetron and granisetron block central cortical-induced vomiting. Headache is the most fre- tion with other antiemetics for treating chemotherapy- quently reported adverse effect of these medications. DRUGS THAT DECREASE OR Cannabinoids NEUTRALIZE GASTRIC ACID The antiemetic site of action of tetrahydrocannabinol SECRETION (THC) (Marinol) is unknown, although it appears to af- Functionally, the gastric mucosa is divided into three ar- fect the central cerebral cortex axis. The oxyntic (parietal) gland area, which fective in the elderly, primarily because of its side ef- corresponds to the fundus and body of the stomach, se- fects. The antiemetic effect is associated with a high, and cretes hydrogen ions, pepsinogen, and bicarbonate. Ataxia, drowsiness, dry mouth, or orthostatic hypoten- The parietal cells secrete H in response to gastrin, sion may be seen in up to 35% of the older patient pop- cholinergic, and histamine stimulation (Fig. GI absorption is variable, though blood levels cholinergic- and gastrin-induced types of stimulation correlate with efficacy. The bioavailability is not as vari- bring about a receptor-mediated rise in intracellular cal- able if the agent is smoked. The coadministration of cium, an activation of intracellular protein kinases, and prochlorperazine may prevent some of the central nerv- eventually an increased activity of the H –K pump ous system side effects seen with the use of tetrahydro- leading to acid secretion into the gastric lumen. Activation Metoclopramide is a dopamine antagonist that centrally of cAMP-dependent protein kinases initiates the stimu- inhibits stimulation of the CTZ. For further details, of food may result in cephalic–vagal postganglionic see earlier section, Drugs that Increase GI Motility. After food is ingested, Phenothiazine Derivatives gastric distention initiates vagal stimulation and short Phenothiazine derivatives, which include prochlorper- intragastric neural reflexes, both of which increase acid azine (Compazine) and promethazine (Phenergan), act secretion. Proteins in ingested meals also stimulate acid 478 V THERAPEUTIC ASPECTS OF INFLAMMATORY AND SELECTED OTHER CLINICAL DISORDERS Vagus nerve Mast cell Circulation PGE H2-antagonist Atropine H Rs Proglumide Adenylate Gs cyclase 2 ↑Ca2 ↑Ca cAMP ATP Protein kinases ↑H K K Substituted Benzimidazole Cl H (e. The pathways by which secretagogues are believed to stimulate hydrogen ion production and secretion are shown. A, atropine; PGE, prostaglandin E; H, histamine; G, gastrin, Rand Ri s, inhibitory and stimulatory receptor-binding sites; Gand Gi s, inhibitory and stimulatory catalytic subunits; ATP, adenosine triphosphate; ATPase, adenosine triphosphatase. Evidence from animal studies suggests that the mucosal surface, both the local blood supply and the after protein amino acids are converted to amines, gas- ability of the local cells to buffer this ion will ultimately trin is released.

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Martial arts in Japan have been in- fluenced by Zen Buddhism and by the samurai warrior Very few activities have as many legends and myths tradition cheap 100 mg kamagra chewable fast delivery erectile dysfunction and heart disease, which refined many weapons as well as meth- surrounding them as do martial arts generic kamagra chewable 100mg with mastercard erectile dysfunction diabetes type 2 treatment. Some Japanese schools of instruction are included under the title of martial arts, and some of adopted the values of bushido, Japanese for “way of the these were passed down in secrecy for many generations. Martial arts also flourished in Korea, there are many conflicting theories and opinions concern- Vietnam, and Thailand. What is known is that mar- tial arts began in the ancient cultures of Asia, including Martial arts were largely unknown to the Western China, India, and Japan. In both China and India, artifacts world until after 1945, when a few American and British from 2,000 to 4,000 years old have been found with paint- veterans of World War II brought back Japanese martial ings of people striking possible martial arts poses. During the 1970s, there was a Qigong, one of the oldest systems that may be considered surge of interest in martial arts in America, due to several a martial art, is believed by some historians to be 5,000 popular television shows and the charismatic actor Bruce years old or older, originating in ancient China. Today, there are a Buddhist monk from India named Bodhidharma brought martial arts schools all across America, and martial arts 1294 GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 are a multi-billion dollar industry. Martial arts are a popu- plimentary principles of the universe, which are always lar activity for self-defense, sport, exercise, spirituality, interacting, opposing, and influencing each other. Present-day forms of martial associated with such qualities as cold, passivity, dark- arts include kalarippayattu in southern India, escrima in ness, yielding, and inward movement. Yang is associated the Philippines, pentjak silat in Malaysia, karate in Oki- with heat, activity, light, assertiveness, outward move- nawa, aikido in Japan, and capoeira in Brazil. For instance, a Benefits strong (yang) attack is taught to be met by a yin, or yielding, response. Martial arts cultivate an awareness Martial arts teach self-defense, and can improve and use of yin or passive qualities, which are ignored by confidence and self-esteem. Another major tial arts can improve balance, strength, stamina, flexibili- yin/yang concept used in martial arts is that the more one ty, and posture. They also enhance weight loss and im- becomes familiar with violence, the more one learns to prove muscle tone. Some martial arts, such as aikido, teach stress management, improve concentration, and teach peace as their ultimate lesson. Although there are hundreds of different martial Some teachers claim that martial arts can be used as spir- arts, many of them have more similarities than differ- itual practices, bringing balance, peace, and wisdom to ences. Martial arts are generally classified as soft or hard, inter- Description nal or external, yin or yang, but they all need to embrace Basic concepts of martial arts these complementary aspects. Hard arts Many martial arts utilize basic concepts of traditional such as karate focus on developing muscular power and Chinese philosophy. Qi is the fundamental life energy of speed, and the mastery of breaking and throwing tech- the universe. In the body, qi is the invisible vital force that niques delivered with devastating impact. All martial arts emphasize is now the general term for an entire group of Japanese breathing techniques. Karate emphasizes offensive and defensive cises are designed to improve the flow of qi in the body, moves, and avoids grappling and wrestling. There are many legends taught how to deliver quick, powerful blows with nearly concerning martial arts masters who had such control of every part of the body, including dangerous kicks with their qi that they could throw opponents across rooms the legs. Some schools teach “full contact” karate, for development and use of qi are termed internal martial which students wear protective equipment to absorb the arts. Kung fu means “skill” in Chinese, and is the generic Many martial arts combine internal and external methods. On the meridians there are certain Kung fu consists of thousands of hard and soft tech- points (acupoints) where qi accumulates. Yin and yang are the two separate but com- to invent a martial art that emphasized non-aggression. GALE ENCYCLOPEDIA OF ALTERNATIVE MEDICINE 2 1295 In Japanese, aikido means “connecting with life energy. Aikido Some schools allow students to attend as many classes also teaches internal methods of cultivating qi energy. Two to three classes per week are recom- teaches the philosophical ideals of love and harmony as mended. Some schools charge a flat fee for Judo means “gentle way” in Japanese and was de- training from beginner to expert. Many schools require veloped as an educational tool by a teacher named Jigoro students to regularly participate in competitions, and fees Kano in the 1800s.

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