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The test is a measure of the rate at which red blood cells settle out of mixed venous blood over a specified period isoptin 40mg pulse pressure 55 mmhg. The test requires that a blood sample is aspirated into a calibrated sedimentation tube and blood is allowed to settle usually for 60 minutes purchase 240mg isoptin arrhythmia medicine. Stomach contents which have a low pH are refluxed into the oesophagus and the oesophageal mucosa has very little purchase isoptin 40mg with visa prehypertension kidney disease, if any, protection against acidic contents. A12 C A mixture of magnesium hydroxide and aluminium salts in antacid prepara- tions is referred to as co-magaldrox. Antacid preparations are used for the symptomatic management of dyspepsia, gastro-oesophageal reflux and gastric pain. Co-magaldrox preparations have the advantage that they eliminate the side-effects of magnesium salts (diarrhoea) and aluminium salts (constipation) as they cancel each other out. Patients should be advised not to take antacid preparations at the same time as other medications as antacids may impair absorption of the other drugs. Antacids may damage enteric-coated tablets, resulting in the dissolution of the drug in the stomach, thus defeating the purpose of using an enteric-coated formulation. A13 E Some drugs may cause phototoxic or photoallergic reactions if the patient is exposed to ultraviolet light. When patients taking amiodarone (for arrhyth- mias) are exposed to direct sunlight or to sun lamps, photosensitivity may occur owing to a phototoxic reaction. A skin reaction may occur and this may continue for some weeks after treatment when amiodarone is stopped. Patients using amiodarone should be advised to use total sunblock preparations, to wear protective clothing and to avoid exposure to sun. Test 4: Answers 197 A14 A Immunoglobulins are used in clinical practice to induce passive immunity and therefore to present immediate protection against an infectious disease. Normal immunoglobulin presents antibodies against several infectious diseases, whereas specific immunoglobulins present a specific antibody such as hepatitis B immunoglobulin. The human donor material is tested for presence of hepatitis B surface antigen and for antibodies against hepatitis C virus and human immunodeficiency virus. Human immunoglobulins are preferred to antisera (immunoglobulins) as they are associated with a lower incidence of hypersensitivity reactions. A15 B Glue ear, also referred to as sero-mucinous otitis media, is a condition where there is an accumulation of viscous mucous fluid in the middle ear, usually occurring after repeated attacks of acute otitis media. Glue ear may also be found in association with inflammation of the sinuses and blockage of the eustachian tube. Deafness or difficulty in hearing is usually the presenting symptom and in some cases this may go unnoticed and lead to permanent hearing loss. A16 B Hepatitis C is a viral infection that is transmitted through contact with contam- inated blood such as when sharing needles and through intravenous drug misuse or the transfusion of infected blood. In hepatitis C, the aim of treatment is to achieve the clearance of the virus, which is sustained for at least 6 months after treatment has stopped. Peginterferon alfa consists of a polyethylene glycol-conjugated 198 Test 4: Answers derivative of interferon alfa. Pegylation results in increasing the availability of interferon in blood and therefore halflife is extended so that the dosing frequency that is required is reduced. A17 A A stroke, also referred to as a cerebrovascular accident, is due to acute neuro- logical dysfunction of vascular origin in focal areas of the brain. It may present as a completed stroke, where the signs and symptoms occur for more than 24 h, or a transient ischaemic attack if the signs disappear within a few minutes or at most within 24 h.

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The prostate gland is a mixture of capsular 7 There are three cloned subtypes for the a1-adrenoceptor: a1A discount 240 mg isoptin fast delivery blood pressure chart 16 year old, a1B and and stromal tissue buy isoptin 240 mg on line blood pressure medication hair growth, rich in a1 adrenoceptors discount isoptin 120mg free shipping blood pressure levels in adults, and glandular a. Thea isthepredominantsubtypeinthebladderbaseandprostatic 1D 1A tissue under the influence of androgens. Both these, the a urethra, whereas contraction of vascular smooth muscle is largely receptors and androgens, are targets for drug therapy. Hence, a1A selectivity would confer, at cause the bladder itself has few a receptors, it is possible least in principle, ‘prostatic’ selectivity. But selectivity determined in vitro against cloned a1 receptors only poorly predicts in vivo to use selective a1-blockade without affecting bladder ‘uroselectivity’, which also diminishes as dose is increased (compare contraction. They cause sig- increased in balding scalps (Tartagni M, Schonauer M, Cicinelli E et al 1 2004 Intermittent low-dose finasteride is as effective as daily nificant increases (compared to placebo) in objective mea- administration for the treatment of hirsute women. Adverse effects areshortlived,doserelated,andcomprise headache, flushing, nasal congestion and dyspepsia. Sildenafil is contraindicated in patients who evidence is not conclusive, drug therapy is thought to under- are taking organic nitrates, for their metabolism is blocked lie 25% of cases, reputedly from antidepressants (selective and severe and acute hypotension result. This latter could be viewed as a mixed compressed between the engorged sinusoids and the sur- blessing in erectile dysfunction, but is important for the use rounding and firm tunica albuginea, causing the near-total of this drug class in pulmonary hypertension. Theprincipalneu- Alprostadil is a stable form of prostaglandin E1, a power- rotransmitterisnitricoxide,whichactsbyraisingintracellular ful vasodilator (see p. Its dose (5–20 micrograms) is titrated initially in the doctor’s emergence as an agent for erectile dysfunction is an exam- surgery, aiming for an erection lasting for not more than ple of serendipity in drug development. The drug reminiscent of the disturbed colour perception caused by digoxin (in should be taken 1 h before intercourse in an initial dose overdose), except here patients report yellowed vision (xanthopsia). It is effective (up to 80%) for can cause priapism requiring aspiration of the corpora psychogenic and neurogenic erectile dysfunction by intra- cavernosa and injection of an a-adrenoceptor agonist, cavernosal self-injection shortly before intercourse (efficacy e. Summary • The actions of drugs on the kidney are of an importance antihypertensive efficacy than loop diuretics. It is among the functions of drugs to help • Potassium retention with hyperkalaemia can occur with reduce losses of desirable substances and increase losses of potassium-sparing diuretics, which block sodium transport undesired substances. The symptoms of benign prostatic hyperplasia are • Loop diuretics, acting on the ascending loop of Henle, are partially relieved either by a1-adrenoceptor blockade or by the most effective, and are used mainly to treat the oedema inhibiting synthesis of dihydrotestosterone in the prostate. Cough is useful when it effectively expels secretions or for- Central nervous system eign objects from the respiratory tract, i. Asthma, rhinosinusitis (causing postnasal drip) Cough is also under substantial voluntary control and can and oesophageal reflux are the commonest causes of persis- be inducible by psychogenic factors (e. Recently, eosinophilic bronchitis has been recog- cough during the quiet parts of a musical concert) and re- nised as a possibly significant cause; it responds well to duced by a placebo. The British Thoracic Society publishes guidelines on cough and its management that are available online. Small children are prone to swallow Opioids are usually formulated as linctuses for antitussive lozenges, so a sweet on a stick may be preferred. Deciding on which agent to use depends largely on Linctuses are demulcent preparations that can be used whether sedation and analgesia may be useful actions of alone and as vehicles for other specific antitussive agents. Hence methadone or diamorphine linctus may Their exact constitution is not critical, and medical students be preferred in patients with advanced bronchial carcinoma. It was discovered that a dramine, can suppress cough by non-H1-receptor actions; large number of children came to the surgery often the doses needed cause substantial drowsiness so that complaining of cough, and they were given the linctus, combination with other drugs, such as pholcodine and but instead oftheir using itas a medicine, they tookit to dextromethorphan, is common in over-the-counter cough an old woman out in Smithfield, who gave them each a remedies. Respira- ture4may be used to give the inhalation a therapeutic smell tory mucus consists largely of water and its slimy character (aromatic inhalation). This manoeuvre may have more is due to glycoproteins cross-linked together by disulphide than a placebo effect by promoting secretion of a dilute mu- bonds.

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Stool bulking agents order 240 mg isoptin overnight delivery blood pressure normal or high, which add fibre to the diet order isoptin 120 mg free shipping heart attack 30s, are the treatment of choice for simple constipation purchase 40mg isoptin with mastercard heart attack toni braxton babyface. They act by in- Senna, available as a biologically standardised prepara- creasing the volume and lowering the viscosity of intestinal tion, is widely used to relieve constipation and to empty contents to produce a soft bulky stool, which encourages the bowel for investigative procedures and surgery. They should be taken with liberal quanti- combination with the faecal softeners poloxamer 188 ties of fluid (at least 2 L daily). Evidence from rodent studies indica- Individual preparations tes a possible carcinogenic risk, and long-term exposure to Bran is the residue left when flour is made from cereals; it danthron should be avoided. Enemas produce defaeca- Some inorganic salts retain water in the intestinal lumen tion by softening faeces and distending the bowel. They or, if given as hypertonic solution, withdraw it from the are used in preparation for surgery, radiological examina- body. Preparations with sodium phosphate, will suffice but magnesium sulphate (Epsom salts) is used which is poorly absorbed and so retains water in the gut, when a more powerful effect is needed. Taken orally, it is un- affected by small intestinal disaccharidases, is not absorbed Contraindications and thus acts as an osmotic laxative. Lactulose is also used in the treatment of hepatic inal pain, inflammatory bowel disease or obstruction. Enemas containing treatment should be with enemas, but digital removal, tra- phosphate or citrate effectively evacuate the distal colon ditionally ordered by a senior and performed by a junior and can be useful for treating obstinate constipation in el- doctor, may occasionally be required. A combination of Thesofteningpropertiesoftheseagentsareusefulintheman- genetic predisposition and environmental factors produces agement of anal fissure (see below) and haemorrhoids. The goal Drastic purgatives (castor oil, cascara, jalap,5 colocynth, 6Crohn and his colleagues Oppenheimer and Ginzberg, all from the phenolphthalein and podophyllum) are obsolete. Mount Sinai Hospital in New York, published a case series describing a necrotising granulomatous inflammatory disease of the terminal ileum 4 in 1932. He precedence means that his surname alone is now associated with the ‘seizedherpropertybeforeshewasquitedeadandtoreupthewillsothat disease he initially termed ‘terminal ileitis’. Allergic reactions include More recently, immunosuppressive therapy has found rash, fever and lymphadenitis; rarely leucopenia and agran- an important role. Males may suffer from reversible oligos- has been introduced and this is likely to produce a number permia and reduced sperm motility. Asacol tablets are coated in a resin, which dissolves Aminosalicylates only at pH 7 or higher, favouring its release in the distal il- eum and colon. Mesalazine prepara- three), and may also be used for treatment of an acute at- tions are available in oral, enema and suppository forms. Sulfasalazine is poorly absorbed Corticosteroid from the small intestine, and colonic bacteria split the Enemas and suppositories. Foam-based preparations ap- cortisone or placebo, stating: ‘It was judged that if the physician proceeded on the assumption that every patient might be receiving pear to coat the colonic mucosa more efficiently than potent cortisone, and if he also had the right to stop treatment at any the aqueous formulations. It is important to ing disease, although anecdotally some patients with ileo- start with a dose that will bring the inflammatory process colonic disease may also respond. Once Adverse effects including alcohol intolerance, peripheral remission has been attained the dose can be tailed down neuropathy and the risk of antibiotic-associated diarrhoea very slowly over a period of 6–8 weeks. Very severe attacks of ulcerative colitis necessitate hospital There is evidence that liquid diets based on amino acids (el- treatment with intravenous corticosteroid; parenteral corti- emental diets) or oligopeptides (semi-elemental diets) for costeroid should also be considered in patients unrespon- 4–6 weeks are as effective as corticosteroids in controlling sive to other medical management. Crohn’s disease, although relapse is common when the The main danger is toxic dilatation of the colon and per- treatment stops. Significant clinical unpalatable even with flavourings and they often have to improvement should be seen within 72 h.

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The tumors is that they ofen expand and impinge upon altered sensation around the gluteal region toward the other structures purchase 120 mg isoptin visa pulse pressure 37. The patient underwent a course of radiotherapy purchase isoptin 40mg visa blood pressure medication make you feel better, had the renal tumor excised purchase 120mg isoptin mastercard blood pressure exercise, and is currently undergoing a course The X-ray appeared on frst inspection unremarkable. The superior thoracic aperture is open, allowing continuity with the neck; the inferior thoracic aperture is • a left and a right pleural cavity, each surrounding a closed by the diaphragm. Superiorthoracic aperture Left pleural cavity Rib I Manubrium of sternum Ribs Xiphoid process Inferior thoracic aperture Fig. It contains the heart, esophagus, trachea, major nerves, and Themediastinum acts as a conduit for structures that pass major systemic blood vessels. The esophagus, vagus nerves, and thoracic duct pass This also means that the mediastinum can be entered sur­ through the mediastinum as they course between the gically without opening the pleural cavities. Another important feature of the pleural cavities is that The phrenic nerves, which originate in the neck, also they extend above the level of rib I. The apex of each lung pass through the mediastinum to penetrate and supply the actually extends into the root of the neck. The thorax not only contains the lungs but also The thoracic wall consists of skeletal elements and provides the machinery necessary-the diaphragm, tho­ muscles (Fig. Because of the domed shape of the diaphragm, the The manubrium of sternum, angled posteriorly on the thoracic wall also offers protection to some important body of sternum at the manubriosternal joint, forms the abdominal viscera. As these ribs curve posteriorly, extensive attachment sites for muscles of the neck, each also articulates with the transverse process of its abdomen, back, and upper limbs. At the superior thoracic aperture, the superior aspects of the pleural cavities, which surround the lungs, lie on The joint between the costal margin and sternum lies either side of the entrance to the mediastinum (Fig. In other words, the pass over rib I and the superior part of the pleural cavity posterior margin of the inferior thoracic aperture is infe­ as they enter and leave the mediastinum. Esophagus Common carotid arery Vertebra Tl Superior thoracic aperture Internal jugular vein Subclavian arteryand vein Manubrium of sternum Fig. Diaphragm The diaphragm is not flat; rather, it "balloons" superi­ The musculotendinous diaphragm seals the inferior tho­ orly, on both the right and left sides, to form domes. The esophagus and inferior venacavapenetrate the dia­ Because of the oblique angle of the inferior thoracic phragm; the aorta passes posterior to the diaphragm. The mediastinumisa thick midline partition that extends During development, the lungs grow out of the medias­ from the sternum anteriorly to the thoracic vertebrae pos­ tinum, becoming surrounded by the pleural cavities. As a teriorly, and from the superior thoracic aperture to the infe­ result, the outer surface of each organ is covered by pleura. The inferior part is further subdivided by the pleura, whereas that reflected from the mediastinum at the pericardium, which encloses the pericardia! The costodia­ Pleural cavities phragmatic recess, which is the largest and clinically most The two pleural cavities are situated on either side of the important recess, lies inferiorly between the thoracic wall mediastinum (Fig. The superior thoracic aperture opens directly into theroot Large blood vessels passing between the axillary inlet of the neck (Fig. The superior aspect of each pleural cavity extends Proximal parts of the brachial plexus also pass approximately 2-3 em above rib I and the costal cartilage between the neck and upper limb by passing through the into the neck. Major blood vessels and nerves Abdomen pass in and out of the thorax at the superior thoracic aper­ The diaphragm separates the thorax from the abdomen. Structures that pass between the thorax and abdomen either penetrate the diaphragm or pass posteriorly to it (Fig. Those branches associated mainly with the second to • Numerous other structures that pass between the fourth intercostal spaces also supply the anteromedial thorax and abdomen pass through or posterior to the parts of each breast. The breasts, consisting of secretory glands, superfcial • Vessels and lymphatics associated with lateral parts of fascia, and overlying skin, are in the pectoral region on the breast emerge from or drain into theaxillaryregion each side of the anterior thoracic wall (Fig. Vessels, lymphatics, and nerves associated with the • Lateral and anterior branches of the fourth to sixth breast are as follows: intercostal nerves carry general sensation from the skin of the breast.