By P. Curtis. Elon University.

Trying to tell you adequately about being a clini- cal clerk is similar to trying to make someone into a swimmer on dry land buy cheap retrovir 300mg line. The terms to describe new clinical clerks may vary at different medical centers (“scut monkey purchase retrovir 300 mg amex,” “scut boy,” “scut dog,” “torpedoes”). These euphemistic expressions describing the new clinical clerk acknowledge that the transition, a sort of rite of passage, into the next phase of physician training has occurred. It is hoped that this “So You Want to Be a Scut Monkey” introduction and the information contained in this book will give you a good start as you enter the “hands on” phase of becoming a successful and respected physician. The details provided and length of the written H&P can vary with the particular problem and with the service to which the patient is admitted. History of the Present Illness (HPI): Defines the present illness by quality; quan- tity; setting; anatomic location and radiation; time course, including when it began; whether the complaint is progressing, regressing, or steady; of constant or intermittent frequency; and aggravating, alleviating, and associated factors. The information should be in chrono- logic order, including diagnostic tests done prior to admission. Related history, including previous treatment for the problem, risk factors, and pertinent negatives should be included. Any other significant ongoing problems should be included in the HPI in a separate section or paragraph. For instance, if a patient with poorly controlled diabetes mellitus comes to the emergency room because of chest pain, the HPI would first include information regarding the chest pain followed by a detailed history of the diabetes mellitus. If the diabetes mellitus was well controlled or diet-controlled, the history of the diabetes mellitus is placed in the past medical history. Past Medical History (PMH): Current medications, including OTC medications, vit- amins, and herbals; allergies (drugs and other—include how allergies are manifested); surg- eries; hospitalizations; blood transfusions, include when and how many units and the type of blood product; trauma; stable current and past medical problems unrelated to the HPI.

Systemic absorption of Although atropine sulfate has proved beneficial in pa- these drugs from the conjunctival sac is minimal discount retrovir 300 mg amex, but tients whose bradycardia is accompanied by hypoten- significant absorption and toxicity can occur if the an- sion or ventricular ectopy retrovir 300 mg without prescription, it is generally not otherwise timuscarinic drugs come into contact with the nasal and recommended in this condition. To mini- without hazard, because cardiac work can be increased mize this possibility, pressure should be applied to the without improved perfusion, and ventricular arrhyth- lacrimal sac for a few minutes after topical application mias may occur. Shorter-acting drugs, such as cy- clopentolate and tropicamide, are now favored for this Uses in Anesthesiology application because complete recovery of accommoda- At one time, atropine or scopolamine was routinely ad- tion occurs within 6 to 24 hours and 2 to 6 hours, re- ministered before the induction of general anesthesia to spectively. With the newer, less irritating anesthetics, an- System timuscarinic premedication is not routinely required as an antisialagogue (i. Sedation can occur following scopolamine in the therapy of peptic ulcers (see Chapter 40) because administration, and preanesthetic or postoperative they can reduce gastric acid secretion; they also have agitation has been observed in some patients. High been used as adjunctive therapy in the treatment of ir- serum levels of drugs with antimuscarinic activity can ritable bowel syndrome. Glycopyrrolate bro- crease the pain associated with postprandial spasm of mide (Robinul) has also been given intramuscularly as intestinal smooth muscle by blocking contractile re- a preanesthetic medication with satisfactory results. Some of the agents used for this disor- This agent is a quaternary ammonium compound and der have only antimuscarinic activity (e. Dicyclomine (Bentyl) and oxybutynin (Ditropan) at therapeutic con- Use With Cholinesterase Inhibitors centrations primarily have a direct smooth muscle re- During reversal of competitive neuromuscular block- laxant effect with little antimuscarinic action. However, extra care must be hibited bladder syndrome, bladder spasm, enuresis, and exercised because the prevention of muscarinic recep- urge incontinence. Tolterodine (Detrol), a nonselective tor stimulation eliminates an important early sign of muscarinic antagonist, exhibits functional specificity for cholinergic crisis (see Chapter 12). However, total prevention of involuntary bladder contractions is difficult to Uses in Ophthalmology achieve. The participation of noncholinergic, nonadren- Antimuscarinic drugs are widely used in ophthalmology ergic nerves in bladder contraction may explain this ap- to produce mydriasis and cycloplegia.