Eurax

Jon M. Braverman, M.D.

• Denver Health Medical Center
• University of Colorado School of Medicine
• Denver, CO

Note that lesions of the inferior fibers acne popping eurax 20 gm sale, E acne on cheeks order eurax in india, of the geniculocalcarine tract in Fig acne breakout generic eurax 20 gm with mastercard. Practice drawing the entire optic pathway from the retina to the occipital cortex acne on chest buy 20 gm eurax visa. Figures 3-5A and 3-6 show the actual course of the optic pathways through the cerebrum skin care zurich buy 20 gm eurax amex. Note that visual field testing assays the integrity of large parts of the temporal and occipital lobes and the inferior margin of the parietal lobe skin care with honey buy 20 gm eurax. To test whether you have mastered the anatomy of the visual fields and the hemisected eyeball mnemonic, move the eyeball well forward over the temporal lobe and reason out the field defect that interruption of the anterior part of loop of the geniculocalcarine tract would cause. Remember that the upper half of the visual field falls on the lower half of the retina. Although glasses improve acuity by correcting for a refractive error, they do not improve acuity impaired by opacities of the refracting media of the eye or retinal or optic nerve lesions. If the history or screening test suggests a visual complaint, use a Snellen or Jaeger chart or a Rosenbaum Pocket Vision Screener for a numerical evaluation of acuity and consider referring the Pt to an ophthalmologist for visual field testing, as explained in point b. For a small child or mentally impaired Pt, use a large E printed on a card and have the Pt point in the direction that the cross bars point after you direct E up and down and right and left. Test the acuity of partially blind Pts by having them count the number of fingers held up at various distances. If the Pt cannot see to count fingers, find out whether the Pt can see hand movements. With each eye separately, the Pt fixates on a dot in the center of a grid work held about 30 cm away (Fig. The Ex asks whether the Pt can see each of the four corners and whether any of the squares in the grid are missing or distorted. The Amsler grid serves as a quick screening test, but the tangent screen maps out field defects precisely. The Pt sits 1 or 2 m away from a black screen 1 or 2 m while fixating on its center (with the other eye covered). After mapping the physiologic blind spot, the Ex systematically searches the central field for pathologic blind spots, called scotomas. Chart for recording the central portion of the visual fields, as determined by tangent screen examination. When no tangent screen is present, at the bedside or clinic, the Ex may select a fixation point on the wall and use a laser pointer as a substitute for the white spot. Make sure you keep fixating on the left cross all of the time, but you should also attend to the right cross. As you maintain fixation on the left cross and continue to attend to the right cross, move your face slowly toward the page. Again cover your left eye, fixate on the left cross, and position your head so that the right cross disappears. Put your pencil point in the blind spot and move it very slowly toward the left cross. The blind spot or other scotomas are mapped more accurately on a distant tangent screen than with the short target distance of this experiment. Draw a small X on a piece of paper to fixate on and fasten the paper to a wall, making your own tangent screen. Seat the partner 100 cm away and map out the blind spot, moving the test object from the far right through the blind spot, toward the fixation point. The absence of receptor neurons at the optic papilla or optic nerve head causes the blind spot. Normally the diameter of the blind spot depends on the diameter of the optic disc (Fig. Retinal lesions such as hemorrhages or exudates block penetration of light rays to the receptor neurons or destroy them. Although in theory retinal or optic nerve lesions might cause quadrantic or hemianopic field defects; in practice, this virtually never occurs. Retinal or optic nerve lesions generally cause central scotomas, centrocecal (a central scotoma connected to the blind spot), or paracentral scotomas. Lesions of the chiasm, optic tract, geniculocalcarine tract, or occipital lobe usually are the causes of hemianopic or quadrantanopic field defects (Fig. From the chiasm on back to and including the calcarine cortex, the more posterior the lesion in the optic pathway, the more congruent the field defect in the two eyes. A Pt who suddenly lost visual acuity without blindness would most likely have a macular lesion, if the lesion affects the retina. If the scotoma is large, the Ex can detect it by carefully moving a pencil tip or small white object, the size of a small pearl, very slowly through the central field. With an acute lesion in the optic nerve, the retina may look normal for some weeks before optic atrophy becomes visible. Demonstration of a scotoma by tangent screen examination would establish an organic cause for the loss of acuity. Figure 3-8I shows the visual fields of a 53-year-old hypertensive Pt who complained of headaches, sudden loss of vision on the right side, and blurring of vision in the left eye. The Pt had an infarct of the left occipital lobe, causing the right hemianopia, and a recent hypertensive hemorrhage in the left retina, causing the scotoma. Generalized constrictions of the visual field In addition to the patterned field defects already discussed, some Pts have a generalized constriction of the visual field. Congruous left homonymous hemianopia due to a right posterior cerebral artery infarction. Hold up your left index finger just outside your own peripheral field, in the inferior temporal quadrant. Test all quadrants of each eye separately, each time starting at the limit of the field. After surveying the visual field by the wiggling finger, you can refine the test by asking the Pt to count the number of fingers presented in each of the four quadrants of the visual field of each eye. Then randomly hold up one, two, or five digits (three or four is too complicated) in each quadrant for the Pt to count. As a further refinement, the Ex may present the fingers for counting simultaneously in two separate quadrants of one eye or present wiggling fingers to each field. If you test along the vertical or horizontal axis, you may miss a full quadrant defect, because of the intact fields on the border of the defect. Confrontation is suitable for detecting large erosions of the island of vision by the sea of blindness. The combination of acuity testing, Amsler grid, and confrontation testing, all of which you can complete in a few minutes, will usually disclose visual defects or at least disclose the need for further testing by tangent screen and perimetry. Detailed mapping of the peripheral fields requires perimetry by an ophthalmologist or neurologist. The tangent screen and perimeter, although valuable in themselves, only extend, but do not supplant, confrontation and the other visual tests by the attending physician. Perimetry by the Goldmann manual kinetic perimeter or automated static perimetry of the central visual field can extend the tangent screen and confrontation test. Place your palm on your forehead with your wrist directly between your eyes, while maintaining fixation on a distant point. By closing one eye, you prove that the light rays from the wrist are striking photosensitive areas of the retina, yet the wrist, although visible with one eye open, nearly vanishes with both eyes open. The experiment shows that the medial, overlapping portions of the visual fields undergo suppression during binocular vision (Fig. This physiologic suppression of the overlapping fields of the two eyes rids the visual image of confusing elements. The overlapping, shaded area of the visual fields undergoes physiologic suppression. Suppression amblyopia (amblyopia ex anopsia): If one eye in an infant turns in or out, the infant learns to suppress the image from the errant eye. If suppression continues for the first few years of life, the Pt ultimately becomes completely blind in the deviating eye, even though the retina and visual pathways remain structurally intact. Hold your arms out to the sides, in the upper or lower quadrant, with your index finger pointing up. Rotate your arms forward until your index fingers just come into view in each eye. Notice that you can make out both fingertips at the periphery of your fields, even though you are looking straight ahead. The presentation of two stimuli, such as the two fingers, on opposite sides, is called double or simultaneous stimulation. Technique for simultaneous stimulation of visual fields: Assume the same position as for regular confrontation, but with the Pt keeping both eyes open. Extend your fingers into your inferior temporal quadrants, near, but not beyond, the periphery of your own visual fields. Then wiggle both fingers simultaneously and ask the Pt to point to any finger that moves. Repeat the test in the upper temporal quadrants and then simultaneously stimulate upper and lower nasal and temporal quadrants of one eye at a time. Patients with parietal or parieto-occipital lobe lesions, usually on the right side of the cerebrum, will not attend to the stimulus from the contralateral side when presented with simultaneous stimuli on both sides. In the usual case, when the Pt does not attend to stimuli from the left half of space, the lesion is in the right/ left parietal lobe. However, when tested by confrontation with one finger in the left visual field, no defect is demonstrated. Hemianopia is detected by using one stimulus, whereas visual inattention is detected by using stimuli. If the Pt fails to recognize a stimulus in one-half of a visual field when both halves are stimulated, it is called . Visual inattention means that the Pt does not perceive one of simultaneous right and left-sided stimuli but has no hemianopia when tested with a single stimulus. Patients with right parietal lobe lesions also may fail to attend to auditory or tactile stimuli from the left side (Chapter 10). Complete blindness, with no light perception and no response to a menacing gesture. Sometimes the Pt will deny the blindness and will claim that vision is present Anton syndrome or visual anosognosia. Confrontation visual field techniques in the detection of anterior visual pathway lesions. Sit down with a normal person and, using colored pencils, draw the optic fundus and its vessels. Moreover, you often should use drawings in your clinical notes rather than laborious written descriptions. Turn the rheostat on the ophthalmoscope down a little to avoid too strong a beam of light. With too bright a light, the pupil constricts strongly, thus reducing the view of the retina, and photophobic Pts will flinch to avoid discomfort. It well repays the time required because it will enable you to relax during the procedure. Next focus on a retinal vessel by using whatever lens setting, from 0 to a strong plus or minus that is required to overcome refractive errors. After locating a retinal vessel, follow it along until you find the optic disc (optic papilla). The cup size depends on whether the nerve fibers perforate the lamina cribrosa at its periphery (A) or all over its surface (C). Notice the large white ring of lamina cribrosa between the nerve fibers and the central vessels. Notice how the edematous swelling engulfs and obscures the proximal segments of many vessels. Next, identify the pigment ring around the disc, note the disc color, and the presence or absence of a physiologic cup. Identify the arteries, the thin, brighter appearing vessels, and the thicker, duller appearing veins. Look for venous pulsations where the veins bend over the edge of the physiologic cup. Visible pulsation occurs in nearly 90% of normal Pts when both eyes are examined (Levin, 1978).

A radiopaque contrast material is instilled into the bladder via a Foley catheter acne en la espalda buy discount eurax on-line. This test is performed to look for defects of the urinary system acne reviews generic eurax 20gm with mastercard, for tumors of the bladder skin care qvc buy eurax with a visa, ureters skin care obagi 20 gm eurax sale, and urethra acne fighting foods order eurax discount, or for reflux of urine from the bladder to the ureters acne purchase eurax cheap. Advise the patient to increase po fluids before and after test to aid the kid neys in removal of contrast material. You would expect the plan of care to include: (a) antibiotics and phenazopyridine. Patients with bladder cancer typically exhibit symptoms of: (a) weight loss and low back pain. Teach a patient at risk for testicular cancer to: (a) restrict potassium, phosphate, sodium, and protein in diet. Care of the postoperative nephrectomy patient includes: (a) assessing the wound site for redness, swelling, or drainage. You are caring for a patient who has had a transurethral resection of the prostate for benign prostatic hypertrophy. Symptoms of prostate cancer include: (a) nocturia and intermittent stream of urination. Acute renal failure due to a decrease in circulating blood volume causing diminished renal perfusion is treated with: (a) intravenous fluids. It pre vents dehydration, regulates body temperature, and is the major deterrent of infec tion in the body. When this barrier is broken, whether by surgical incision, wound, cut, or scrape, the primary defense is no longer intact. Macules are small, flat-topped lesions, less than 1 cm in diam eter, similar to a freckle. A wheal is a raised area filled with fluid and usually temporary, such as in hives. A plaque (sticky deposits that attaches to the inner lining of an artery) is greater than 1 cm in diameter, raised, and shallow. Petechiae are smaller than 1 cm in diameter and are usu ally round areas of deposits of blood. Burns are damage to the skin and body tissues caused by flames, heat, cold, fric tion, radiation (sunburn), chemicals, or electricity. First-degree burns are those with injury to the outer layer of skin called the epidermis. A second-degree burn is when the epidermis is burned, as well as the next layer, the dermis. Severe pain, white and reddened areas, swelling, blis ters, and perhaps drainage will be seen. A third-degree burn goes through all the layers of the skin and could involve underlying tissues. Many drugs may make the skin more sensitive to the sun, pro ducing the effect of a sunburn with little exposure. Common medications with this effect include: amiodorone, carbamazepine, furosemide, naproxen, oral contra ceptives, piroxicam, quinidine, quinolones, sulfonamides, sulfonulureas, tetracy clines, and thiazides, among others. When large portions of the face, chest, hands, feet, genitalia, or joints have sustained a large second or third-degree burn, prompt medical attention is necessary. If smoke inhalation has occurred, or if the nasal hairs are singed, or if quantities of soot are present around the face, assess for adequacy of breathing and damage to the respiratory tract. The patient breathes into a machine, a spirometer, which records changes in the lung size with inhalation and exhalation and the time it takes to perform this test. Treatment choices depend on the degree of burn and the amount of body surface area that was burned. Any second-degree burn greater than 5 to 10 percent of surface area and all third-degree burns belong in a hospital, preferably within a specialized burn unit. All electrical burns and burns of the ears, eyes, face, hands, feet, and perineum require hospital care, as do chem ical burns and burns in infants or the elderly. Inflammation of the skin as a result of contact with an irritating substance such as a chemical, foreign substance, medication, or contact with a plant, such as poison ivy. Often the patient has a history or a family history of asthma, allergy, or 404 Medical-Surgical Nursing Demystified eczema. However, if the patient is atopic, frequent exac erbations and remissions may occur with unknown etiology. Early detection is of the utmost importance because a cure is obtainable in the early stages. Skin cancer is usually divided into three major subtypes: basal cell, the most common; squamous cell, which is the second most common; and melanoma, the most fearsome. Basal cell carcinomas are directly related to sun damage, with most lesions occurring in sun exposed areas. Squamous cell carcinomas are often due to sun-exposure, may be difficult to distinguish from some changes in the skin, and spread more readily. Melanoma is the most deadly form of skin cancer; it usually occurs on the face or upper back. New skin cells are made in the epidermis, which then push the older cells toward the surface where they are shed. Solar exposure can interrupt this process, causing cells to divide at an unusual rate, which may lead to a cancer. Those individuals with a large amount of exposure to ultraviolet radiation, which appears to be cumulative, are more at risk to develop cancerous tumors. Exposure to greater 406 Medical-Surgical Nursing Demystified amounts of x-rays also increase the risk for skin cancers, as does arsenic which is a metal found in the environment and in our food. People who take immunosup presant medications are at a greater risk for skin cancers as are fair-skinned peo ple and those with a family history of skin cancer. Mela noma is staged by determining thickness of the lesion, and the extent to which it has spread. Each surface area is evaluated microscopically, to ascertain that no cancer cells are present in the remaining tissue. Cellulitis is an infection of the skin, caused by bacteria that enter the skin through an opening. The legs are the most common site of cellulitis, although it may occur anywhere bacteria enters. Bacteria may enter through fissures in the feet from fungal infections, through cracks in dry skin, from insect bites, or cuts from shaving. The elderly, immunocompromised patients, and patients with lymphedema, diabetes, or poor circulation are at greatest risk. A severe cellulitis of deep tissue, necrotizing fasciitis, is caused by a streptococcal bacteria and is considered a medical emergency. If fever and body aches accompany the infection or if the face is involved or the area is extensive, hospi talization may be necessary. Empiric treatment is started immediately and is effec tive against the most common bacteria. A pressure ulcer starts on the skin and often progresses to deeper tissue; it is caused by impaired circulation to the tissue from pressure over a period of time. Those often affected are confined to a wheelchair or bed, and unable to move themselves, not reducing the pressure frequently enough. It can take as little as a few hours in one position for a stage one pressure ulcer to develop. The usual sites of pressure ulcers, or bedsores, are on bony prominences, such as the buttocks, sacrum, heels, knees, and hips. Assessment tools are available to predict the risk of pressure ulcers devel oping. A commonly used scale is the Braden scale which includes such criteria as friction, the nutritional status of the patient, mobility and activity levels, moisture exposure of the skin and any limitations of sensory perception. The very factors that caused the pressure ulcer are the same factors that interfere with healing. Setbacks are common, such as wound infection, cellulitis, and sepsis, which can lead to death. Debridement methods include surgery, topical enzymatics, and mechanical debridement. It may be intentional, as with surgery, or unin tentional, as a result of trauma. Types of wounds include surgical, penetrating (such as a knife), crushing, burn, lacerations, bites, (human, animal), ulcers, and pressure ulcers. Immediately after a wound occurs, inflammation begins with platelet aggre gation. A prolifera tive phase starts when the epidermal cells move toward the wound, and cover the approximated wound edges, usually by the third day. Primary intention happens when edges are closely approximated and new tissue, or granulation, knits the close edges together. Wound healing by secondary intention occurs in a larger wound where the edges are further apart. The granulation tissue builds across the surface of the wound forming a large clot and sequentially, a larger scar. Items which need to be assessed in patients with wounds include chronic disease, such as dia betes, impaired circulation; nutrition; hydration status; and immunosuppression, such as corticosteroid or chemotherapeutic agents. Epithelialization of wound occurs within 48 hours, wound strength is 60 percent of previous strength within 4 months. An 414 Medical-Surgical Nursing Demystified intradermal test, where the allergen is injected just under the skin, or a patch test, where an allergen patch is placed on the skin, may also be used. Skin Biopsy A skin biopsy is usually done to diagnose an abnormal area of the skin, such as a growth or mole for cancer It is also used to diagnose a bacterial or fungal skin infection or other abnormal skin condition. A sample of tissue is taken for analy sis by a pathologist to determine if cellular changes have occurred. A stain is added to a culture on a slide which will show blue for Gram positive cells or red for Gram-negative cells. This is the first step in determining the identity of a particular bacterial sample and can be used to allow empiric anti biotics to be started, before the final culture is ready. It measures the amount of IgE antibody that reacts specifically with the suspected allergen. Patient teaching for risk reduction of skin cancer should include: (a) having suspicious moles checked by a dermatologist. Appropriate treatment for a patient with cellulitis includes: (a) petrolatum and vitamin A and D ointment. For your patient with a mild dermatitis rash, you would encourage: (a) washing the area with an antiseptic soap frequently to keep the area clean. Your nursing treat ments would include: (a) keeping both the legs elevated as much as possible. To clean a wound, it is best to use: (a) hydrogen peroxide to bubble away the debris. A balance should be maintained to keep concentrations of both fluids and electrolytes in the proper areas for normal function. The cell walls are semi permeable to allow for movement (diffusion) of molecules. The higher hydrostatic pressure in the vessel causes fluids to move into the interstitial areas which have lower pres sure, allowing the fluid to build up. Hypertonic solutions have a concentration greater than 300 mOsm/L and exert a greater pressure, which pulls water from the isotonic area to the hyper tonic solution in an attempt to equalize the osmolarity. Aldosterone signals the tubules within the nephrons in the kidneys to reabsorb sodium and therefore water. Renin is secreted by the kidneys in responses to changes in sodium or fluid vol ume. In the circulation, renin acts on a plasma protein called renin substrate (also called angiotensinogen), converting it to angiotensin I. Natriuretic peptides are secreted in response to increases in blood volume and blood pressure. The lungs and the kidneys are integral in maintaining the normal acid-base balance. The body constantly monitors the pH level and makes adjust ments in an attempt to correct any abnormalities. In an attempt to maintain as normal an internal environment as possible, the body will attempt to compensate for the changes that are occurring. Low levels of sodium may be due to loss of sodium from the body, movement of sodium from the blood to other spaces, or dilution of sodium concentration within the plasma.

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Syndromes

• What part of the abdomen is affected? All over? Lower or upper? Right, left, or middle? Around the navel?
• Protanopia -- difficulty telling the difference between blue/green and red/green
• Injection drug use with contaminated needles and syringes
• MRI
• Pills or tablets, taken by mouth
• Take the drugs your doctor told you to take with a small sip of water.
• Sore throat
• If blood flow is stopped for longer than a few seconds, the brain cannot get oxygen. Brain cells can die, causing permanent damage.
• Adults: 750 to 2,400
• Failure to thrive

References

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• Barthold JS, Kumasi-Rivers K, Upadhyay J, et al: Testicular position in the androgen insensitivity syndrome: implications for the role of androgens in testicular descent, J Urol 164(2):497n501, 2000.
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• Anderson JL, Adams CD, Antman EM, et al., American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013;127:e663-828.
• Desai MY, Dhillon A, To AC. Cardiac magnetic resonance in hypertrophic cardiomyopathy. Curr Cardiol Rep. 2011;13:67-76.
• O'Donnell MJ, Xavier D, Liu L, et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010;376:112-23.