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The Stationery Office best order colospa spasms kidney area, London discount colospa 135 mg line xanax muscle relaxer, 1999; and on the Department of Constitutional Affairs (formerly Lord Chancellor’s Department) purchase colospa with paypal muscle relaxant sciatica. Sexual Assualt Examination 61 Chapter 3 Sexual Assault Examination Deborah Rogers and Mary Newton 1. All health professionals who have the potential to encounter victims of sexual assaults should have some understanding of the acute and chronic health problems that may ensue from an assault. However, the pri- mary clinical forensic assessment of complainants and suspects of sexual assault should only be conducted by doctors and nurses who have acquired specialist knowledge, skills, and attitudes during theoretical and practical training. There are many types of sexual assault, only some of which involve pen- etration of a body cavity. This chapter encourages the practitioner to under- take an evidence-based forensic medical examination and to consider the nature of the allegation, persistence data, and any available intelligence. The chapter commences by addressing the basic principles of the medical examination for both complainants and suspects of sexual assault. Although the first concern of the forensic practitioner is always the medical care of the patient, thereafter the retrieval and preservation of forensic evidence is para- mount because this material may be critical for the elimination of a suspect, identification of the assailant, and the prosecution of the case. Thus, it is imper- ative that all forensic practitioners understand the basic principles of the foren- sic analysis. Thereafter, the text is divided into sections covering the relevant body areas and fluids. Each body cavity section commences with information regard- From: Clinical Forensic Medicine: A Physician’s Guide, 2nd Edition Edited by: M. This specialist knowledge is manda- tory for the reliable documentation and interpretation of any medical findings. The practical aspects—which samples to obtain, how to obtain them, and the clinical details required by the forensic scientist—are then addressed, because this takes priority over the clinical forensic assessment. The medical findings in cases of sexual assault should always be addressed in the context of the injuries and other medical problems associated with con- sensual sexual practices. Therefore, each section summarizes the information that is available in the literature regarding the noninfectious medical compli- cations of consensual sexual practices and possible nonsexual explanations for the findings. The type, site, and frequency of the injuries described in asso- ciation with sexual assaults that relate to each body area are then discussed. Unfortunately, space does not allow for a critical appraisal of all the chronic medical findings purported to be associated with child sexual abuse, and the reader should refer to more substantive texts and review papers for this infor- mation (1–3). Throughout all the stages of the clinical forensic assessment, the forensic practitioner must avoid partisanship while remaining sensitive to the immense psychological and physical trauma that a complainant may have incurred. Although presented at the end of the chapter, the continuing care of the com- plainant is essentially an ongoing process throughout and beyond the primary clinical forensic assessment. Immediate Care The first health care professional to encounter the patient must give urgent attention to any immediate medical needs that are apparent, e. Nonetheless, it may be possible to have a health care worker retain any clothing or sanitary wear that is removed from a complainant until this can be handed to someone with specialist knowledge of forensic packag- ing. Timing of the Examination Although in general terms the clinical forensic assessment should occur as soon as possible, reference to the persistence data given under the relevant sections will help the forensic practitioner determine whether the examination of a complainant should be conducted during out-of-office hours or deferred Sexual Assualt Examination 63 until the next day. Even when the nature of the assault suggests there is unlikely to be any forensic evidence, the timing of the examination should be influenced by the speed with which clinical signs, such as reddening, will fade. Place of the Examination Specially designed facilities used exclusively for the examination of com- plainants of sexual offenses are available in many countries. The complainant may wish to have a friend or relative present for all or part of the examination, and this wish should be accommodated. Suspects are usually examined in the medical room of the police station and may wish to have a legal representative present. During the examinations of both complainants and suspects, the local ethical guidance regarding the conduct of intimate examinations should be followed (4). Consent Informed consent must be sought for each stage of the clinical forensic assessment, including the use of any specialist techniques or equipment (e. When obtaining this consent, the patient and/or parent should be advised that the practitioner is unable to guarantee confidentiality of the material gleaned during the medical examination because a judge or other presiding court officer can rule that the practitioner should breach medical confidentiality. If photo documentation is to form part of the medical examination, the patient should be advised in ad- vance of the means of storage and its potential uses (see Subheading 2.

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From these numerical values order colospa now muscle relaxant alcoholism, what results would you expect for Mrs Goodwin’s peripheral perfusion and respiratory status (e cheap colospa line back spasms 20 weeks pregnant. Formulate a care plan which includes rationale for choice of prescribed drug therapies aimed at reducing afterload discount generic colospa uk spasms leg, preload and myocardial oxygen consumption, increasing cardiac output and peripheral perfusion, whilst preventing further ischaemia. Frequently encountered dysrhythmias are also described following the normal conduction pathway. The etymologically more accurate term ‘dysrhythmia’ is used rather than the common term ‘arrhythmia’, since, except for asystole, rhythms are problematic rather than absent. Cardiac rhythm affects blood pressure: blood pressure=heart rate×stroke volume×systemic vascular resistance Atrioventricular dyssychrony (almost all dysrhythmias) causes loss of ‘atrial kick’, reducing stroke volume by one-fifth (Cohn & Gilroy-Doohan 1996). Some specific drugs and treatments are identified with each dysrhythmia discussed; other drugs may be seen in practice, and users should consult data sheets or pharmacopaedias for detailed information on drugs. Common problems and approaches include: conduction: ■ bradycardic dysrhythmias may need chronotropes (e. Ventricular conduction may be blocked with: • β-blockers (esmolol, sotalol, propanolol), which inhibit beta receptors (see Chapter 34) • calcium antagonists (amiodarone, verapamil) which increase refractory periods of action potentials may be used to slow ventricular conduction. Monitors are neither an end in themselves, nor a substitute for observing patients, but rather a means to providing information which should be evaluated in context of the whole person. Action potential Ion exchange between intracellular and extracellular fluid creates transmembrane imbalances, enabling muscular (electrical) activity, hence action potential (Figure 21. When electrical activity is absent, resting sinoatrial potential is about −90 millivolts (mv). The three main ions involved with action potential are ■ sodium ■ potassium ■ calcium Extracellular concentrations of about 140 mmol/litre of sodium and 4. Action potential changes along conduction pathways to ‘overpacing’ lower pacemakers. This lasts only milliseconds before resting charge of −90 mv (repolarisation) is restored. Action potential of pacemaker cells (sinoatrial node, atrioventricular node and conducting fibres) differs from other myocytes, reflecting the automaticity of pacemaker cells. This prevents cardiac muscle responding to further stimulus, thus ensuring coordinated contraction. Plateau time influences contractile strength of muscle fibres (which determines stroke volume). Hypercalcaemia increases contractility; calcium antagonists can reduce excitability. Catecholamines increase depolarisation (increase duration of phase 4) in pacemaker cells, hence causing tachycardia. Vagal stimulation (mediated through acetylcholine) slows depolarisation (decreases slope in phase 4) of pacemaker cells, causing bradycardia. Atrial/junctional dysrhythmias Sinus arrhythmia This occurs when inspiration increases intrathoracic pressure sufficiently to cause parasympathetic (vagal) stimulation, slowing sinoatrial rate; on expiration, the faster rate is restored. It occurs mainly in children and younger people; high ventilator tidal volumes may cause sinus arrhythmia. Bradycardic children should be given oxygen urgently (unless there are other obvious causes for bradycardia). Obvious causes should be removed, so that oxygen should be optimised (on avoiding oxygen toxicity, see Chapter 18). Drugs include ■ anticholinergics (atropine) block parasympathetic stimulation ■ sympathetic stimulants (adrenaline, isoprenaline). Severe refractory sinus bradycardia may necessitate pacing (temporary or permanent). Young children often have intrinsic (normal) rates exceeding 100 contractions/minute. Cardiac output is usually adequate with rates below 180 beats/min (bpm) provided venous return remains adequate, although rates above 140 bpm are usually treated. Tachycardia reduces diastolic time, and so reduces coronary artery filling time and left ventricular muscle oxygen supply, while increasing left ventricular workload and myocardial oxygen demand. Supraventricular tachycardia This severely compromises both cardiac output (rates of 160–250 (Cohn & Gilroy- Doohan 1996)) and myocardial oxygenation, usually necessitating treatment.

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These are oils cheap colospa master card gas spasms in stomach, balms generic colospa 135 mg muscle relaxers not working, creams buy colospa 135mg on line spasms muscle twitching, ointments, teas, tinctures, capsules, tablets, and syrups. Although herbs are available in these forms, some herbs should only be administered externally and not used internally. While herbal therapies provide patients with a therapeutic effect, they can also leave the patient exposed to hazards. When combined with conventional therapies, herbal therapies can produce a toxic effect or an adverse reaction. The nurse should ask if the patient is taking herbal therapies and, if so, for what condition. The patient should be taught about herbal therapies, the risks and benefits, and then given clear instructions on how to continue herbal thera- pies while undergoing conventional treatment—if approved by the patient’s healthcare provider. The patient should not take an herb unless which of the following infor- mation in on the package? A patient who complains about palpitations and who is undergoing herbal therapy may be taking (a) comfrey. The nurse should instruct the patient on how to monitor for adverse side effects of herbal therapies. Comfrey is an ointment used to relieve swelling associated with abra- sions and sprains. We developed a respect for those words because vitamins and minerals are necessary to remain healthy. Therefore, it is critical that you assess the patient for vitamin and mineral deficiencies and administer the prescribed therapy to restore the patient’s nutritional balance. In this chapter you’ll learn about vitamins and minerals and how to assess patients for deficiencies. You’ll also learn about vitamin therapy and mineral therapy and how to educate your patient about proper nutrition. Vitamins Vitamins are organic chemicals that are required for metabolic activities neces- sary for tissue growth and healing. Under normal conditions, only a small amount of vitamins—which are provided by eating a well balanced diet—are necessary. Likewise, patients who do not have a well-balanced diet (such as the elderly, alcoholics, children, and those who go on fad diets) might also develop a vita- min deficiency. That would require the patient to take vitamin supplements to assure there are sufficient vitamins to support his or her metabolism. Expect to provide vitamin supplements for patients who have: • Conditions that inhibit absorption of food. The pre- vious food pyramid placed everyone in the same group, which is not realistic. The revised food pyramid is organized into five color-coded groups, each with a general recommendation. Three ounces of whole grain bread, rice, cereal, crackers, or pasta every day (orange). Fat-soluble vitamins Fat-soluble vitamins are absorbed by the intestinal tract following the same metabolism as used with fat. Any condition that interferes with the absorption of fats will also interfere with the absorption of fat-soluble vitamins. Fat-soluble vitamins are stored in the liver, fatty tissues and muscle and remain in the body longer than water-soluble vitamins. Vitamin A Vitamin A (Acon, Aquasol) helps to maintain epithelial tissue, eyes, hair and bone growth. It is important to keep in mind that Vitamin A is stored in the liver for up to two years, which can result in inadvertent toxicity if the patient is administered large doses of Vitamin A. Vitamin D Vitamin D, absorbed in the small intestine with the assistance of bile salts, is necessary for the intestines to absorb calcium. Contraindications Mineral oil, cholestyramine, alcohol, and antilipemic drugs decrease the absorption of vitamin A. Contraindications Hypercalcemia, hypervitaminosis D, or renal osteodys- trophy with hyperphosphatemia. Use with caution in patients with arteriosclerosis, hyperphosphatemia, hypersensitivity to vitamin D, and renal or cardiac impairment. There are two forms of Vitamin D: D2, called ergocalciferol; and D3, called cholecalciferol.

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Sterilize stock solutions of carbohydrates (50% w/v) separately by autoclaving or order colospa cheap muscle relaxant hydrochloride, preferably purchase colospa 135 mg on-line muscle relaxant recreational, by filtration (0 buy colospa 135 mg on line muscle relaxant uses. Place yolks in sterile container and mix aseptically with equal volume of sterile 0. For heart infusion agar, add 15 g agar/L and boil to dissolve before dispensing and sterilizing. Kligler Iron Agar Polypeptone peptone 20 g Lactose 20 g Dextrose 1 g NaCl 5 g Ferric ammonium citrate 0. Lysine Decarboxylase Broth (Falkow) (for Salmonella) Gelysate or peptone 5 g Yeast extract 3 g Glucose 1 g L-Lysine 5 g Bromcresol purple 0. Lysine Iron Agar (Edwards and Fife) Gelysate or peptone 5 g Yeast extract 3 g Glucose 1 g L-Lysine hydrochloride 10 g Ferric ammonium citrate 0. MacConkey Agar Proteose peptone or polypeptone 3 g Peptone or gelysate17 g Lactose 10 g 395 Bile salts No. Autoclave 15 min at 121°C, cool to 45-50°C, and pour 20 ml portions into sterile 15 x 100 mm petri dishes. Motility Test Medium (Semisolid) Beef extract 3 g Peptone or gelysate10 g NaCl 5 g Agar 4 g Distilled water 1 liter Heat with agitation and boil 1-2 min to dissolve agar. For Salmonella: Dispense 20 ml portions into 20 x 150 mm screw- cap tubes, replacing caps loosely. Agar and blood should both be at 45-46°C before blood is added and plates are poured. Suspend ingredients of Medium 1 in distilled water, mix thoroughly, and heat with occasional agitation. Prepare Medium 2 in the same manner as Medium 1, except autoclave 15 min at 121°C. Prepare stock solution of novobiocin by adding 20 mg monosodium novobiocin per ml of distilled water. Make fresh stock each time of use, or store frozen at - 10°C in the dark (compound is light-sensitive) for not more than 1 month (half-life is several months at 4°C). Trypticase (Tryptic) Soy Agar Trypticase peptone 15 g Phytone peptone 5 g NaCl 5 g Agar 15 g Distilled water 1 liter Heat with agitation to dissolve agar. Tryptone (Tryptophane) Broth, 1% Tryptone or trypticase 10 g Distilled water 1 liter Dissolve and dispense 5 ml portions into 16 x 125 or 16 x 150 mm test tubes. Tryptone Yeast Extract Agar Tryptone 10 g Yeast extract 1 g *Carbohydrate 10 g Bromcresol purple 0. Before use, test all batches of dye for toxicity with known positive and negative test microorganisms. If colony is taken from blood agar plate, any carry-over of red blood cells can give false-positive reaction. Stain is stable l month at 4°C or may be stored frozen indefinitely (50 ml portions). To determine staining time (after 2-3 days refrigeration at 4°C), stain a known flagellated organism on 3 or more cleaned slides for various times (e. Staining Procedure 411 To prepare suspension, pick small amount of growth from 18-24 h plate (equivalent to 1 mm colony). To prepare slide, pass cleaned slide through blue part of burner flame several times to remove residual dirt. Crystal violet in dilute alcohol Crystal violet (90% dye content) 2 g Ethanol (95%) 20 ml Distilled water 80 ml 2. Alcoholic solution of iodine Potassium iodide 10 g Iodine 10 g Ethanol (70%) 500 ml 2. Ethanol Solution, 70% Ethanol, 95% 700 ml Distilled wateradd to final volume of 950 m. Formalinized Physiological Saline Solution Formaldehyde solution (36-38%) 6 ml NaCl 8. Filter in steamer, while hot, through 2 layers of analytical grade filter paper (e. Giemsa Stain Giemsa powder 1 g Glycerol 66 ml Methanol (absolute) 66 ml Distilled stain in glycerol by heating 1. For double strength (20%) glycerin solution, use 200 ml glycerin and 800 ml distilled water. Rinse mortar and pestle with amount of water needed to bring total volume to 300 ml.