By O. Raid. Philadelphia University.

Although I had been diagnosed with asthma buy pepcid 20 mg cheap, I had not had an attack since I was in middle school cheap 20 mg pepcid amex. Consequently cheap pepcid 20 mg line, the physicians attributed my attacks to high stress buy pepcid 20mg lowest price, lack of sleep, and poor eating habits. It had become clear to me that my unrelenting drive to provide my students with a sound math and science education without properly balancing teaching and my personal life negatively impacted my ability to serve my students. I believe this experience taught me a lesson that will prove to be invaluable as a physician. Establishing an equilibrium between my service and my personal life as a physician will allow me to remain connected to the human experience; thus enabling me to serve my patients with more compassion and effectiveness. Throughout my travels and experiences I have seen the unfortunate consequences of not having equitable, quality health care both domestically and abroad. Illness marks a point in many peoples lives where they are most vulnerable, thus making a patients faith and health care providers vital to their healing process. My pursuit to blend the roles of science and religion formulate my firm belief that health care providers are caretakers of Gods children and have a responsibility to all of humanity. Nevertheless, I realize my effectiveness and success as a physician will be predicated mostly on my ability to harmonize my ambition with my purpose. Therefore, I will always answer bewildered looks with the assurance that my faith and my abilities will allow me to serve my patients and achieve what I have always strived for and firmly believe in, balance. We never made it to see a horror movie; but our night was nothing close to mundane, when we became innocent victims to gang crossfire. As we descended my front door stairs two gunshots were fired and one person fell to the floor. I vividly recall holding him in my arms, and while he lost blood I almost lost my mind. While this event started me on my quest to become a medical doctor, at that moment all I could envision was a life of despondency. According to author Jennifer Holloway, tragedy is a substance which can ignite the soul. As fast as despondency had filled my heart, it was now gone; I was consumed by anger, frustration and motivation to change my lifes direction. By the end of the year I excelled as the top student in biology, received the Inorganic Chemistry Achievement Award and was encouraged to become a tutor in general biology and chemistry. Questions raised by students challenged my understanding of scientific concepts and their application in patient care. While shadowing doctors, I was introduced to triaging, patient diet monitoring and transitioning from diagnosis to treatment. This exposed me to some of the immense responsibilities of a doctor, but my 4 experience helping in the cancer ward was where I learned the necessity of humanity in a physician and how it can be used to treat patients. Peering through a window I saw Cynthia, a seven-year-old girl diagnosed with terminal cancer, laughing uncontrollably after watching her doctor make funny faces. For a moment not only did Cynthia forget that she was dying, but her smile expressed joy and the beauty of being alive. This taught me that a physician, in addition to being knowledgeable and courageous, should show compassion to patients. It also became clear to me that a patients emotional comfort is as important as their physical health, and are both factors that a physician considers while providing patient care. Although focused on medicine, I was introduced to research through the Louis Stokes Alliance for Minority Participation in Science. Here, I learned organic synthesis techniques, while working on a project to elucidate the chemical mechanisms of oxygen- protein binding and its relationships to anemia. I also received the United Negro College Fund/Merck Science Initiative Research Scholarship that allowed me to experience cutting edge research in Medicinal Chemistry, with a number of world-class scientists. At Merck Research Labs, I learned the fundamentals of synthesizing novel compounds for drug discovery, and we focused on treatments for cardiac atrial fibrillation. This internship changed my view of medication and their origins, and left me with a deep appreciation of the challenges of medicinal research. I also now understand that medical doctors and research scientists have similar responsibilities: to solve current and future health issues that we face. Today as I move forward on the journey to become a physician I never lose sight of the ultimate goal; to turn the dying face of a best friend into the smiling glow of a patient, just like Cynthias. But with the right medications, a physicians compassion and some luck, sickness can be overcome, and the patient helped. In time and with hard work it will be my privilege to possess the responsibilities of a physician in caring for life. Over several weeks I witnessed his losing battle, not only with a terminal illness but also with cultural incongruence and a continual feeling of unease, thousands of miles away from home. Jorge was a victim of health care inequality, a subject that has been at the forefront of my mind since enrolling in Race and Medicine in America during my sophomore year. The course revealed to me the historically poor distribution of quality medical attention and how treatment continually evades socio-economically disadvantaged communities. This unfortunate reality inspired me to take an interest in treating these populations, in hopes of helping to improve the care for our countrys poor and underserved.

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Refer patient for specialist care Step 4: Persistent poor control Consider trial of: Very high dose inhaled steroid Addition of a fourth drug e discount pepcid 20 mg free shipping. Prognosis Most children and teenagers with asthma improve as Prevalence they get older generic 20mg pepcid fast delivery, although asthma may recur in adult life order 20 mg pepcid visa. Em- All patients should be advised not to smoke and to avoid physematous spaces are found in 50% of smokers aged potential work allergens purchase 20mg pepcid amex. Chronic bronchitis and emphysema Sex Denition M > F Chronicbronchitishasaclinicaldenitionofcoughpro- ductive of sputum on most days for at least 3 months of Geography the year for more than 1 year. New regression equations for predicting Patients with severe asthma (indicated by need for admission) and adverse peak expiratory flow in adults. Expiratory wheeze and cough are present Virtually conned to cigarette smokers and related to the but the cough is dry. As emphysema be- causes pan-acinar emphysema and accounts for 5% of comesmoresevereothersignsbecomeevidentinclud- patients with emphysema. Patients tend to be young (below 40 years) piration, poor chest expansion (a hyperinated chest especiallyifsmokers,inwhomthediseaseismuchworse. The pink puffer is typical of relatively of airways and luminal narrowing resulting in airway pure emphysema and the blue bloater is typical of rel- obstruction. Mucus respiratory bronchioles whilst the more distal alveolar gland hypertrophy and hyperplasia can be quantied by ducts and air spaces tend to be well preserved. The theReidindexwhichistheratioofglandtowallthickness alveolar dilatation results from loss of elastic recoil in within the bronchus. Smoking Microscopy also causes glandular hypertrophy (chronic bronchi- Both emphysema and chronic bronchitis are inam- tis) and has an adverse effect on surfactant favouring matory diseases of the lung. In pan-acinar emphysema destruction involves the Eosinophilsarealsoseenespeciallyinchronicbronchitis, whole of the acinus. Theclinicalfeaturesdepend Complications on the degrees of chronic bronchitis and of emphysema Airway obstruction and alveolar destruction eventually contributing to the overall picture. Pulmonary vasculature re- ductive of sputum, expiratory wheeze and progres- sponds to hypoxia by vasoconstriction which increases sive shortness of breath. Symptoms of emphysema the arterial pressure, causing pulmonary artery hyper- are dominated by progressive breathlessness, initially tension, which leads to right heart failure (cor pul- only on exertion but eventually on mild exertion such monale). Cyanosis, hypercapnia and cor r Bronchodilators:Shortactingbronchodilatorspro- pulmonale develop only late in the disease after pro- duce signicant clinical benet, helping patients gressive decline in lung function. Amoxycillin resis- feel less short of breath (although objective im- tant Haemophilus respiratory infections are common in provement in lung function tests may be slight). Long acting 2 agonists and bacterial or mixed infections are common resulting in longactinganticholinergicsimprovelungfunction, major morbidity and mortality. There may also be a deciency sputum is purulent, should be given promptly in of bloodvesselsintheperipheralhalfofthelungelds acute exacerbations in an attempt to minimise lung in comparison to the proximal vessels. Management 6 Surgical management 1 Non-pharmacological: By far the most important fac- r Patients of young age who are otherwise t and well tor that can affect the prognosis and progression of may be considered for lung or heart/lung trans- chronic obstructive pulmonary disease is stopping plantation. Physio- diopulmonary bypass and is performed through a therapy may help clear sputum, and pulmonary re- sternotomy. Bilateral or single lung transplants are habilitation programmes improve exercise capacity performed through a lateral thoracotomy possibly and quality of life. The lung is prone to rejection and patient sufciently to overcome the obstruction, in the thus transbronchial biopsies are now used for rou- process of which the patients sleep is disturbed, although tine monitoring. Less than half notice that they have a restless or unrefreshing sleep, and about a third Prognosis complain of morning headache (due to carbon dioxide 50% of patients with severe breathlessness die within 5 retention). Sleepingpartnerswillhavenoticedloudsnor- years although even in severe cases stopping smoking ing in 95% and often notice the snoreapnoeachoke improves the prognosis. Classical anatomy is a long soft palate, large neck Sleep apnoea/Pickwickian syndrome and excess tissue around the tonsils. Denition Sleep apnoea represents the cessation of airow at the Complications level of the nostrils and mouth lasting at least 10 seconds, Oxygen saturations may fall very low. The pulmonary thepatientissaidtosufferfromsleepapnoeaifmorethan vasculature responds to hypoxia by vasoconstriction 15 such episodes occur in any 1 hour of sleep. Hypoxia also increases arrhythmias and there is an increased risk Prevalence of stroke and myocardial infarction. Investigations A simple sleep study with overnight pulse oximetry to- Sex gether with a history from sleeping companion may be Male preponderance. Polycythaemia tive pulmonary disease and alcohol or other sedatives (raised haemoglobin and packed cell volume) may occur which exacerbate the problem by causing hypotonia and in advanced cases. Apnoea can be divided into the following: Management 1 Central apnoea when there is depression of the respi- Non-pharmacological treatment includes weight loss, ratory drive, e.

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Impaired hepatic function and renal insufciency are not necessarily contraindicated but the dose should be limited to 2 mg buy discount pepcid 20mg on-line. Erectile Dysfunction 177 time a careful assessment should be made to balance benet against risk buy 20 mg pepcid mastercard, especially in patients with hepatic insufciency 20 mg pepcid fast delivery. The effect on patients who have had prostatectomy or pelvic surgery is also not known buy discount pepcid 20 mg online. Caution should be taken when treating patients with uncontrolled hyper- tension and patients with hypotension. Antihypertensives and nitrates (especially short-acting nitrates) do have the potential to cause an acute episode of hypoten- sion. Caution also needs to be taken in patients who have penile deformity or other conditions that may predispose them to priapism. There are few absolute contraindications for use, but include combinations with other dopamine agonists or antagonists and patients with severe unstable heart conditions or other con- ditions where any sexual activity creates unacceptable risk. Nausea tends to diminish with subsequent dosing, so that by the eighth dose this is usually no longer a problem. Where nausea and emesis is a concern, it is safe to prescribe ondanse- tron hydrochloride, prochlorperazine maleate, or domperidone prophylactically (79). Rhinitis and pharyngitis have been reported in a very small proportion on men, and in a very few cases (0. It has been implicated as an aphrodisiac (85) but has not been properly considered as a therapeutic agent until recently. The pro- posed mechanism of action of yohimbine is to block presynaptic alpha2 receptors while sparing the postsynaptic alpha1 receptors. The effect of this is to enhance the release of norepinephrine in the central nervous system. It reaches a plasma concentration in just 1015 min and has a very short half-life of just over 30 min. Guay and Spark (84) suggest that previous studies using yohimbine have not been successful because their subjects included a large proportion of men who were smokers. They hypothesized that smoking reduces the effectiveness of yohimbine and so their study excluded this subgroup. They reported few side effects with the low doses used (mild anxiety in one subject and hot ashes in another). From their evidence, they suggested that yohimbine could be useful for a subset of men with mild disease or few risk factors, and recommended that yohimbine should be studied further. Random controlled trails would be useful to determine the safety and efcacy of this established pharmaceutical agent. The initial doses of these agents are given under supervision as there is also a risk of a hypotensive episode needing medical attention. Patients must be taught how to inject safely and using a proper technique so as to avoid the problems of brosis which indicates that treatment must be discontinued. In the doseresponse study of 296 men with various etiologies, they found that the erections would last longer the higher the dose injected. This pattern was repeated in their other placebo-controlled experiments with increasing numbers of subjects to determine optimum dose and to conrm efcacy and safety. The treatment was discontinued by 6% of men due to the main side effect, which is penile pain. This effect was actu- ally experienced by half of the men participating, but not on all occasions. Five percent of the subjects experienced prolonged erections although most men continued the treatment. Other rare adverse effects occurred in 1% of the men and were thought to be related to hypotension. It is for this reason that the initial prescribed dose must be delivered in the clinical setting under medical supervision. This mode of delivery is recommended for a small subset of individuals who may have problems with injecting. Werthman and Rajfer (87) only reported making observations up to 10 min after administration of the drug whereas Padma-Nathan et al. They increased the dose delivered to each indi- vidual up to a maximum of 1000 mg. The number of men achieving the maximum penile response rose linearly with increasing dose. However, its little understood pharmacology is very different from that of morphine.