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Vertical lines: these are imaginary and most often used with the sub- costal and intertubercular planes 260mg extra super avana with visa erectile dysfunction types, for purposes of description order extra super avana 260 mg online impotence at 80, to subdi- Surface markings of the abdominal viscera (Fig cheap 260mg extra super avana with amex erectile dysfunction medication nhs. They pass vertically cheap kamagra oral jelly 100 mg otc, on Liver: the lower border of the liver is usually just palpable on deep either side purchase viagra extra dosage cheap, through the point halfway between the anterior superior inspiration in slim individuals. More commonly used, for descrip- face of the diaphragm and reaches a level just below the nipple on each tion of pain location, are quadrants. The surface marking corresponds to a point where the lat- ally and the cartilages of the 11th and 12th ribs posteriorly. The pubic Pancreas: the pancreatic neck lies on the level of the transpyloric tubercle is an important landmark and is identifiable on the superior plane (L1). Kidneys: the kidney hila lie on the level of the transpyloric plane The superficial inguinal ring (see Fig. The lower pole of the right kidney usually extends 3 cm below the defect in the external oblique aponeurosis. Appendix: McBurney’s point represents the surface marking for the The spermatic cord can be felt passing medial to the pubic tubercle base of the appendix. It extends as a de- Bladder: in adults the bladder is a pelvic organ and can be palpated pression in the midline from the xiphoid process to the symphysis pubis. Surface anatomy of the abdomen 53 23 The pelvis Icthe bony and ligamentous pelvis Iliac crest Anterior gluteal line Iliac fossa Inferior gluteal line Posterior superior Anterior superior iliac spine iliac spine Anterior inferior Posterior gluteal line Auricular iliac spine surface Acetabulum Greater sciatic notch Obturator foramen Iliopectineal Pubic tubercle Spine of ischium line Pubic crest Lesser sciatic notch Pubic tubercle Body of pubis Ischial tuberosity Pubic Ramus of ischium Inferior ramus symphysis Fig. Prostate Obturator fascia The blue line represents the origin Obturator internus of levator ani from the obturator Anterior edge Levator prostatae fascia of levator ani 54 Abdomen and pelvis The pelvis is bounded posteriorly by the sacrum and coccyx and antero- The pelvic cavity laterally by the innominate bones. The pelvic brim (also termed the pelvic inlet) separates the pelvis into the false pelvis (above) and the true pelvis (below). By adulthood the constituent bones have fused together at the behind, the ischial tuberosities laterally and the pubic arch anteriorly. Posteriorly each hip bone articulates with the sacrum at the The true pelvis (pelvic cavity) lies between the inlet and outlet. It runs back- wards from the anterior superior iliac spine to the posterior superior The ligaments of the pelvis (Fig. The outer surface of the ilium is termed the gluteal sur- Sacrotuberous ligament: extends from the lateral part of the sacrum face as it is where the gluteal muscles are attached. The The above ligaments, together with the sacro-iliac ligaments, bind auricular surface of the ilium articulates with the sacrum at the sacro- the sacrum and coccyx to the os and prevent excessive movement at the iliac joints (synovial joints). In addition, these ligaments create the greater and iliac ligaments strengthen the sacro-iliac joints. The pelvic floor muscles: support the viscera; produce a sphincter Ischium: comprises a spine on its posterior part which demarcates action on the rectum and vagina and help to produce increases in intra- the greater (above) and lesser sciatic (below) notches. The rectum, urethra and vagina tuberosity is a thickening on the lower part of the body of the ischium (in the female) traverse the pelvic floor to gain access to the exterior.

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Morphine is the most commonly used analgesic drug The clearance of morphine and its active metabolite order extra super avana once a day erectile dysfunction otc meds, administered via the epidural route because it is potent discount extra super avana 260 mg without prescription doctor for erectile dysfunction, morphine-6-glucuronide depends on adequate renal efficacious effective 260mg extra super avana causes of erectile dysfunction in younger males, and hydrophilic 100mg kamagra polo free shipping. The elderly are particularly susceptible to ac- drug generic 10 mg cialis visa, the slower the onset and the longer the duration cumulation of the drugs, hence respiratory depression of action following epidural administration. Morphine, like all opioids, passes through or continuous infusion of morphine is used to provide the placenta rapidly and has been associated with pro- pain relief in thoracic and abdominal surgical patients longation of labor in pregnant women and respiratory and in cancer patients at high risk for developing side depression in the newborn. Since morphine Morphine and other opioids exhibit intense sedative does not produce anesthesia via the epidural route, the effects and increased respiratory depression when com- patient is able to move about normally; motor function bined with other sedatives, such as alcohol or barbitu- is preserved. Increased sedation and toxicity are observed is that certain types of pain are relatively unresponsive, when morphine is administered in combination with such as that associated with visceral stimuli, as in pan- the psychotropic drugs, such as chlorpromazine and creatitis, and neuropathic pain from nerve deafferenta- monoamine oxidase inhibitors, or the anxiolytics, such tion. Patients must be administered repeatedly at 30- to 45minute in- may also itch because of histamine release. The use of an in- Codeine and Other Phenanthrene dwelling catheter allows the patient to administer the Derivatives drug at frequent intervals for pain relief. It is widely used as an opioid antitussive be- cause at antitussive doses it has few side effects and has excellent oral bioavailability. Codeine is metabolized in Adverse Effects and Contraindications part to morphine, which is believed to account for its The opioids generally have a high level of safety when analgesic effect. However, there are several opioids in combination with nonopioids for the relief of notable exceptions. The administration of 30 mg of codeine in combi- contraindicated in patients with hypersensitivity reac- nation with aspirin is equivalent in analgesic effect to tions to the opioids. For this rea- tered codeine has about one-tenth to one-fifth the po- son, meperidine use in patients with renal or liver insuf- tency of morphine for the relief of pain. Convulsant ac- produce vasodilation and hypotension than does mor- tivity has been documented in elderly patients given phine. Adverse effects and drug interactions with codeine Meperidine differs from morphine in that it has far are similar to those reported for morphine, although less antitussive effect and little constipative effect. Overdose in children results in the drug is particularly useful in cancer patients and in pul- same effects as overdose of morphine, such as respira- monary patients, in whom the cough reflex must remain tory depression, miosis, and coma; these symptoms are intact. Although meperidine produces Hydrocodone (Hycodan), oxycodone (Roxicodone), spasms of the biliary tract and colon, such spasms are of dihydrocodeine, hydromorphone (Dilaudid), and oxy- shorter duration than those produced by morphine. However, respiratory depression in the newborn vere pain or for their antipyretic effects; they are often has not been observed, and meperidine clearance in the used in combination with nonopioid analgesics. The newborn is rapid in that it does not rely upon conjuga- drugs vary in potency, but their pharmacological effects tion to glucuronides.

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In early is one of the drugs used to treat acute lymphoblastic pregnancy cheap 260 mg extra super avana amex erectile dysfunction pills cialis, potential effects on organogenesis in the leukemia purchase extra super avana 260 mg mastercard impotence jelqing. This is important because chloro- rent cancer purchase 260 mg extra super avana free shipping erectile dysfunction drugs side effects, using a different chemotherapeutic agent quine will only kill organisms infecting erythrocytes generic extra super levitra 100 mg without a prescription. This is be- Because of his travel history order line levitra professional, this patient should be cause of the fact that cancer cells can become resistant suspected of infection with P. In therefore assumed to have infected hepatocytes as this patient’s case, paclitaxel (a microtubule inhibitor) well as erythrocytes. The physician for killing the organisms in hepatocytes and should be chose to use irinotecan, an agent that inhibits topoi- given with chloroquine when infection by P. Quinolone should be prescribed to a patient with suspected antibiotics are sensitive to all of the pathogens in this P. However, Neisseria gonorrhoeae exhibits the highest zone of inhibition in microbiologic suscepti- 6 The answer is B: Administer ganciclovir. This patient is in (and make the patient more sensitive) include in- a state of hyperfbrinolysis, likely because of the fbri- creased age, hypothermia, pregnancy, sepsis, acute nolytic drug she was given. An anesthetic gas with Administration of abciximab would worsen this pa- high blood solubility, such as halothane, dissolves tient’s bleeding. Administration of clopidogrel The solubility in blood is ranked in the following would worsen this patient’s bleeding. Administration of urokinase would worsen agent for this patient because of its rapid induction this patient’s bleeding. Vincristine is the only is good agent for this patient because it has a rapid drug in this list that inhibits proliferation by blocking induction time. Vincristine disrupts the formation of micro- would not necessarily be preferred or not preferred as tubules in cells. It primarily affects cells in antibiotics that worked in the past (such as penicillin the G2 phase of the cell cycle. His overall undergoes a conformational change to mediate fusion condition would deteriorate with dexamethasone ad- of the virion and cell membranes. The transdermal patch must binds viral gp41 to prevent the conformational change be used with caution because death resulting from necessary to fuse the viral and host cell membranes. It competi- (B) This patient has no underlying reason to have tively inhibits viral reverse transcriptase’s ability to cardiomyopathy. Ritonavir should be discon- with a Neisseria gonorrhoeae infection, which is treat- tinued in a patient who develops pancreatitis. Cilastatin is added to prevent renal breakdown of tion is suggestive of infection with Neisseria gonor- imipenem. It is used in certain cases gonorrhea because most strains are now resistant to of urethritis and cystitis.