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She had worn the patch continuously for 7 days prior the detachment and there was no history of unprotected sexual intercourse during the patch-free period purchase 100mg viagra super active with mastercard loss of erectile dysfunction causes. You have informed her that there is no need for emergency contraception and one of the options above order generic viagra super active online erectile dysfunction in diabetes. Progestogen implant Instructions For each clinical scenario below, choose the single most appropriate contraceptive method from the above list of options. She is on day 14 of her cycle and feels that this is not the right time for her to conceive, as she recently got promoted at work. A 40-year-old para 2 woman with twins was readmitted with high temperature 2 weeks afer an emergency caesarean section for failure to progress. She is on broad spectrum antibiotics for endometritis with good clinical improvement. She has hypertension, type 2 diabetes and had a pulmonary embolism at 32 weeks’ gestation, for which she is on anticoagulants. She is struggling to cope with the twins and the multiple appointments due to her medical conditions. She wishes to have a long-term reversible contraceptive method prior to discharge. NuvaRing Instructions For each clinical scenario below, choose the single most appropriate contraceptive method from the above list of options. A 15-year-old girl comes to see you for reliable contraceptive advice afer a condom mishap. Her menstrual cycles are irregular, heavy and painful to the extent that she had to miss school during the heavy days during the last three cycles. A 38-year-old nulliparous woman seeks your advice on the most efective method of contraception afer recent diagnosis of breast cancer. A 20-year-old nulliparous woman attends the family planning clinic to discuss the contraceptive options that are suitable for her. She is not keen on pills or injections and had issues with compliance in the past, and doesn’t like the idea of having devices in the vagina or uterus. Bilateral ligation of vas deferens (Vasectomy) Instructions For each contraceptive action and uses described below, choose the most likely group of contraceptive method from the list above. This is an alternative form of birth control in women who cannot take oestrogen and, if the usual time of ingestion is delayed for more than 3 hours, an alternative form of birth control should be used for the following 48 hours. This provides contraception for 8–10 years and, if placed within 120 hours of unprotected intercourse, can also be used as a form of emergency contraception. Causes changes in the cervical mucus but does not cause inhibition of ovulation C. Inhibits ovulation in 50–60% of menstrual cycles and also relies on other mechanisms such as alteration in the cervical mucus and endometrium J. Inhibits ovulation in 30% of menstrual cycles and also relies on other mechanisms such as alteration in the cervical mucus and endometrium K.

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The glomus cell is the site of oxygen sensing order cheap viagra super active online erectile dysfunction young, a poorly understood process involving oxygen-sensitive voltage-gated potassium channels and a variety of neurotransmitters and modulators buy generic viagra super active on-line erectile dysfunction frequency age. Features of the hypoxic ventilatory response include stimulation by: • Decreased PaO2, not oxygen content, therefore there is no response to anaemia, carboxyhaemoglobin. Stimulation results in an increase in depth and rate of breathing, brady- cardia, hypertension, increased bronchiolar tone, and adrenal stimulation. Ventilation Respiratory muscles Numerous muscle groups are involved in changing lung volume. Their co-ordination by the medullary respiratory neurones and interaction with each other are complex. Minor abnormalities of this system result in airway collapse by seemingly minor physiological challenges such as sleep or sedative drugs. Contraction of the diaphragm causes reduction in the zone of apposition (the area around the outside of the diaphragm, which has direct contact with the inside of the ribcage), thus increasing lung volume by a ‘piston-like’ action. This is the most energy efficient way of converting diaphragm contraction into lung expansion, and is impaired either by hyperexpanded lung or by raised intra-abdominal pressure. Contraction of the diaphragm also increases thoracic volume by flattening of the diaphragm dome and expansion of the lower ribcage (Fig. In vivo, these actions all occur together in a co-ordinated fashion and are significantly altered by posture (see below) and respiratory pattern. Contraction of these muscles increases intra-abdominal pressure, resulting in cephalad displacement of the diaphragm. Active expiration occurs during stimulated breathing if the minute volume is approximately >35L/min, or in the spontaneously breathing patient under general anaesthetic. Inactive during normal ventilation, these are employed with increasing respiratory rate and tidal volume. Ventilation of the lower lung is twice that of the upper, which matches the preferential perfusion to the lower lung. In anaesthetized patients movement of non-dependent areas of the diaphragm dominates. Upper chest and pelvis need support to allow free movement of the abdomen and chest. Pathophysiology of ventilatory failure Ventilatory failure occurs when a patient cannot achieve the required minute volume of alveolar ventilation. Chronic respiratory diseases may lead to a reduction in the normal physiological response to hypercapnia.

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Pharmacologic Effects When administered in the absence of opioids purchase viagra super active 100 mg with visa causes of erectile dysfunction include quizlet, naloxone has no significant effects buy viagra super active online now erectile dysfunction specialist doctor. If administered to a patient who is already receiving opioids, naloxone will reverse analgesia, sedation, euphoria, and respiratory depression. If administered to an individual who is physically dependent on opioids, naloxone will precipitate an immediate withdrawal reaction. Pharmacokinetics Naloxone was traditionally restricted for use in the inpatient setting. Now with new legislation, naloxone is available for use by patients and families in the outpatient setting to help prevent opioid-related deaths from accidental overdose. Therapeutic Uses Reversal of Opioid Overdose Naloxone is the drug of choice for treating overdose with a pure opioid agonist. The drug reverses respiratory depression, coma, and other signs of opioid toxicity. However, the doses required may be higher than those needed to reverse poisoning by pure agonists. Dosage must be carefully titrated when treating toxicity in opioid addicts because the degree of physical dependence in these individuals is usually high and hence an excessive dose of naloxone can transport the patient from a state of poisoning to one of acute withdrawal. Accordingly, treatment should be initiated with a series of small doses rather than one large dose. Because the half-life of naloxone is shorter than that of most opioids, repeated dosing is required until the crisis has passed. If the patient received a dose of naloxone by a friend or family member for a suspected overdose, the patient should be transported by emergency providers to the nearest emergency department for further evaluation. Other Opioid Antagonists Methylnaltrexone Actions and Therapeutic Use Methylnaltrexone [Relistor] and naloxegol [Movantik] are selective mu opioid antagonists indicated for opioid-induced constipation in patients with chronic pain who are taking opioids continuously and who have not responded to standard laxative therapy. Accordingly, the drugs do not decrease analgesia and cannot precipitate opioid withdrawal. Pharmacokinetics Methylnaltrexone is rapidly absorbed after subQ injection, reaching peak plasma levels within 30 minutes. Naloxegol can be taken orally on a daily basis and has a slightly longer half-life (6 to 11 hours) than methylnaltrexone. Methylnaltrexone undergoes minimal metabolism and is excreted in the urine (50%) and feces (50%), primarily as unchanged drug. Adverse Effects, Precautions, and Drug Interactions Methylnaltrexone and naloxegol are generally well tolerated. The most common adverse effects are abdominal pain, flatulence, nausea, dizziness, and diarrhea. In the event of severe or persistent diarrhea, these drugs should be discontinued. Preparations, Dosage, and Administration Methylnaltrexone [Relistor] is available in solution (12 mg/0.

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Because progesterone is unavailable to induce monthly endometrial breakdown discount 25 mg viagra super active with visa erectile dysfunction surgery cost, the excessively proliferative endometrium undergoes spontaneous sloughing at irregular intervals discount viagra super active online mastercard erectile dysfunction in the age of viagra. Treatment has two objectives: the initial goal is cessation of hemorrhage; the long-term goal is to establish a regular monthly cycle. Giving an oral contraceptive twice daily for 5 to 7 days can help stabilize the endometrium and thereby reduce bleeding duration. In one regimen, oral dosing is started 10 to 14 days after the onset of each menstrual period and continued for the next 10 days. Amenorrhea Progestins can induce menstrual flow in selected women who are experiencing amenorrhea. If endogenous estrogen levels are adequate, treatment with a progestin for 5 to 10 days will be followed by withdrawal bleeding when the progestin is stopped. If estrogen levels are low, it may be necessary to induce endometrial proliferation with an estrogen before giving the progestin. Endometrial Carcinoma and Hyperplasia Progestins can provide palliation in women with metastatic endometrial carcinoma, but these drugs do not prolong life. Endometrial hyperplasia, a potentially precancerous condition, can be suppressed with progestins. One progestin—hydroxyprogesterone acetate [Makena]—is approved for preventing preterm birth in women with a singleton pregnancy and a history of preterm delivery. Adverse Effects Up to 20% of patients may experience breast tenderness, headache, abdominal discomfort, arthralgias, and depression. When used continuously for birth control, progestins greatly decrease production of cervical mucus and cause involution of the endometrial layer. Effects on the endometrium lead to spotting, breakthrough bleeding, and irregular menses. Progestins, in combination with estrogen, increase the risk for breast cancer in postmenopausal women. Newer oral progestins—norgestimate and drospirenone—are available in fixed-dose combinations with estradiol sold as Prefest and Angeliq, respectively. Intramuscular progestins are medroxyprogesterone acetate [Depo-Provera] and progesterone (in oil). Medroxyprogesterone acetate is also available in a formulation for subQ injection [Depo-SubQ Provera 104]. Micronized progesterone for intravaginal use is available as progesterone gel [Crinone] and a vaginal insert [Endometrin].

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The mechanism is this:1 alpha -mediated vasoconstriction elevates blood pressure viagra super active 25mg with mastercard icd-9 erectile dysfunction diabetes, which triggers the1 baroreceptor reflex purchase viagra super active 50 mg with visa erectile dysfunction medicine online, causing heart rate to decline. In patients with marginal cardiac reserve, the decrease in cardiac output may compromise tissue perfusion. However, their ability to activate alpha2 2 receptors in the periphery has little clinical significance because there are no therapeutic applications related to activation of peripheral alpha receptors. By activating central alpha receptors, we can2 produce two useful effects: (1) reduction of sympathetic outflow to the heart and blood vessels and (2) relief of severe pain. The central alpha agonists used for2 effects on the heart and blood vessels, and the agents used to relieve pain, are discussed in Chapters 15 and 22, respectively. Clinical Consequences of Beta Activation 1 All of the clinically relevant responses to activation of beta receptors result from1 activating beta receptors in the 1 heart; activation of renal beta receptors is not1 associated with either beneficial or adverse effects. Therapeutic Applications of Beta Activation1 Heart Failure Heart failure is characterized by a reduction in the force of myocardial contraction, resulting in insufficient cardiac output. Because activation of beta1 receptors in the heart has a positive inotropic effect (i. Shock This condition is characterized by profound hypotension and greatly reduced tissue perfusion. By increasing heart rate and force of contraction, beta stimulants can1 increase cardiac output and can thereby improve tissue perfusion. Cardiac Arrest By activating cardiac beta receptors, drugs have a role in initiating contraction1 in asystole or pulseless ventricular rhythms. Initial management focuses on cardiopulmonary resuscitation, external pacing, or defibrillation (whichever is applicable), and identification and treatment of the underlying cause (e. When a beta agonist 1 is indicated, epinephrine, administered intravenously, is the preferred drug. Adverse Effects of Beta Activation1 All of the adverse effects of beta activation result from activating beta receptors1 1 in the heart. Altered Heart Rate or Rhythm Overstimulation of cardiac beta receptors can produce 1 tachycardia (excessive heart rate) and dysrhythmias (irregular heartbeat). Angina Pectoris In some patients, drugs that activate beta receptors can precipitate an attack of1 angina pectoris, a condition characterized by substernal pain in the region of the heart. Anginal pain occurs when cardiac oxygen supply (blood flow) is insufficient to meet cardiac oxygen needs. The most common cause of angina is coronary atherosclerosis (accumulation of lipids and other substances in coronary arteries). Because beta agonists increase cardiac oxygen demand (by1 increasing heart rate and force of contraction), patients with compromised coronary circulation are at risk for an anginal attack. Clinical Consequences of Beta Activation 2 Applications of beta activation are limited to the 2 lungs and the uterus. Drugs used for their beta -activating ability include epinephrine, isoproterenol, and2 albuterol. Therapeutic Applications of Beta Activation2 Asthma Asthma is a chronic condition characterized by inflammation and bronchoconstriction occurring in response to a variety of stimuli.