By A. Pranck. Gannon University. 2018.
The patient should assume a position with his head that causes nystagmus discount 1mg finax with amex, and then attempt to focus the eyes and move them in a position that maximizes his symptoms buy finax 1mg on line. As the nystagmus di- minishes order generic finax canada, the patient should begin to move the head up and down or from side to side while visually fixating on a target. He should attempt to stand and walk while the nystagmus is still present, and (as symptoms improve) should move the head from side to side or up and down while walking (first slowly, then quickly in all directions). Note that pa- tients may have an increase of symptoms as a result of repositioning maneuvers. Both disorders are associated with acute onset vertigo and nystagmus, nausea, and vomiting that may last for 2 wk. The distinction between the two is based on the presence (labyrinthitis) or absence (neuritis) of concomitant hearing loss or tinntus. Prednisone and acyclovir have been found to facilitate recovery, if treatment is initiated within 3 days (com- pared to more than 7 days) after symptom onset. It is characterized by acute attacks of vertigo and ear pressure lasting hours, asso- ciated with tinnitus and sensorineural hearing loss. In addition to vestibulosuppressants, patients may benefit from restricted sodium, caffeine, and nicotine intake. He may benefit from a referral for vision refraction or rehabilitation, as indicated by his deficits. Disposition • Patients with neurologic deficits or suspected central disorders should be admitted. Pa- tients with intractable vomiting or severe dehydration may require inpatient treatment. Seizure may be the sole presenting symptom of a life-threatening ill- ness requiring immediate treatment. The outward expres- sion of a seizure may take many forms: • Generalized seizures involve a loss of consciousness. The symptoms may 116 Emergency Medicine sponteously resolve, recur, spread to contiguous cortical regions (jacksonian march), or become secondarily generalized. The episode classically begins with a blank stare, and (occasionally) loss of muscle tone, resulting in a fall. Epigastric sensations are most common, but affective, cognitive, or sensory symptoms also occur. Secondary generaliza- tion may occur so rapidly that the preceding partial component is not recognized, and only the altered mental status is observed. Diagnosis History • If the seizure activity has terminated prior to the patient’s arrival in the emergency department, a description of the event from a reliable witness is invaluable. A description of events immedi- ately preceding the seizure activity should also be sought, including any complaints of pain or focal neurologic deficits. If the patient has an altered level of conscious- ness, is he in a postictal state? When a differential diagnosis is formulated for a particular patient, the following studies may be helpful in ruling in or excluding specific etiologies: • Laboratory • Glucose should be checked on all first-time seizure patients. Although commonly ordered, routine electrolytes, calcium and magnesium have low diagnostic yield in otherwise healthy patients with a first seizure. The patient should be positioned in such a way as to protect the airway in case of vomiting, and suction should be readily available. Supplemental oxygen should be administered by nasal cannula or face mask, and the patient placed on continuous pulse oximetry. Most seizures are brief (<2 min) and there is no evidence that a single, brief seizure has deleterious central nervous system effects. It is usually administered via the intravenous route but is equally effective when given rectally. Acceptable routes of ad- ministration include intravenous, rectal, sublingual, and oral. Unlike diazepam and lorazepam, this agent is well absorbed when given via the intramuscular route be- cause of its water-solubility. After administration, it becomes lipid soluble and, like diazepam, has rapid penetration of the blood-brain barrier as well as a short dura- tion of antiepileptic activity. Acceptable routes of administration include intrana- sal, intramuscular, intravenous, rectal, and buccal. If there is any question as to the necessity of initiating chronic therapy, neurologic consultation is advised. If intubation is required, short-acting paralytics are preferred in order to allow the practitioner to identify ongoing seizure activity. Side effects of the intravenous preparation are attributed to the pro- pylene glycol diluent. These are minimized by infusing at a rate not to exceed 1 mg/kg/ min in children and 50 mg/min in adults. It is highly water-soluble, and is rapidly converted to phenytoin after ad- ministration.
Nevertheless finax 1mg for sale, in many cultures buy finax online pills, particularly in many traditional (sometimes also called communitarian) communities effective finax 1mg, these values are rejec- ted and individual rights are systematically denied to women and children – often in the name of cultural integrity, customary values and the defence of collective rights, all within the same human rights discourse. This chapter attempts to give a theoretical background that can help health care profes- sionals make diYcult ethical choices in multicultural environments. Most of the practical examples mentioned in this article are from Tanzania, for the simple reason that during my visiting lectureship at the University of Dar es Salaam these local customs, the problems involved in them and attempts to solve these problems are the ones that have become most familiar to me. On the one hand, it is evident that the promotion of women’s and children’s health and well-being not only means Wnding the best possible medical cure avail- able, but also indicates commitment to the promotion of the individual’s social status in families, communities and in social order in general. On the other hand, sometimes promoting individuals’ rights and autonomy, par- ticularly women’s and children’s rights and autonomy, can lead into cul- turally based ethical disagreement and value clashes which, for their part, may turn the patients as well as their whole communities away from the help and cure they need the most. To deal with these multicultural issues and their relation to human rights in medical care, we need agreement on ethical norms that can be applied across national and cultural borders. After all, a global set of ethical norms not only needs to be applicable everywhere, it also has to be sensitive to diVerences in cultural traditions as well as diVerences in needs between individuals (and between groups of individuals) in their social contexts. In other words, global bio- ethics needs to try to get away from the misguided polarization between universalism and relativism, on the one hand, and between individualism and collectivism, on the other hand. Sometimes this same debate is discussed within the framework of liberalism and communitarianism, that is, between the protection of individual rights and the promotion of the common good (Kuczewski, 1998; Etzioni, 1999). If we are to Wnd any globally acceptable set of norms, we need to take recent feminist bioethical challenges seriously and try to Wnd a way to promote universal values in a manner that takes the particularity of cultures as well as the special needs of individuals in diVerent situations seriously. Even liberal pluralism based on the universal respect for individual rights can easily turn into relativist subjectivism, which exaggerates an individual’s autonomy, giving the illusion of free choice in a situation in which social pressure directly aVects one’s decisions and actions. Instead, the demand for the respect of collectivist values is usually set within international human rights standards and thus, must gain its plausi- bility by universalization of collective rights. In other words, the culturally relativist demand that we treat the ethical views of diVerent cultures as equals is based on contradictory arguments – the relativity of cultural values and ethical norms is defended by appealing to universal respect for tolerance, equality and collective rights. Finally, in order to Wnd a way to agree on the values that can be universally promoted, we need to make a distinction between the prescriptive and descriptive uses of terms that we use to denote particular cultural features. In other words, when we talk about ‘collectivist’ culture we have to diVerentiate between its universally acceptable, positive elements and its negative features and practices. Thus, we cannot automatically presume a collective culture to be ‘oppressive’ towards its individual members; it can as well be democrati- cally supportive of them. Alternatively, when we talk about ‘individualist’ culture, we cannot presume support for individuals’ self-development and realization of their moral autonomy. All in all, I claim that the main problem in Wnding global bioethical norms is not incompatibility between universalist and relativist reasoning or be- tween individualist and collective ethical positions per se. First, within Multicultural issues in maternal–fetal medicine 41 individualist societies, human rights lack universal protection; in particular, women’s rights are easily ignored. Second, even if we can Wnd a set of values and norms based on these values that can be globally accepted, we do not pay enough attention to their promotion in practice – what are the most accept- able means to promote the shared values and norms in particular cultural contexts? Liberalism and conflicting interests in medical decision-making When we talk about multicultural issues in maternal–fetal medicine, we often start by setting up a polarization between two quite diVerent bioethical frameworks. These approaches are, on the one hand, universalism, which focuses on universal human rights, and on the other hand, relativism, which emphasizes the relativity of cultural belief and value systems. As long as these polarizations remain, there is a tendency to create two opposite bioethical positions – that is, universalist liberal individualism and relativist com- munitarian collectivism. Bioethical thinking in Western pluralist and multicultural democracies is typically based on liberal concepts of justice, demanding the universalization of such individualist values as respect for individual autonomy, protection of individual rights and the promotion of equality and tolerance. On the other hand, this means that we need to let individuals decide on the way they want to live their lives and what kind of cultural identity to maintain. In other words, neither the state nor another individual is allowed to tell somebody what kind of life is ‘the good life’ (Rawls, 1971, 1993; Hellsten, 1999: pp. In a modern pluralist society, we are asked to tolerate diVerent lifestyles and respect diversity in cultural backgrounds within the liberal universalist ethical framework. Even within a liberal framework there are limits to tolerance – diVerences in beliefs and lifestyles can be accepted only if they do not harm someone else or violate someone else’s rights. In modern pluralist society, the most diYcult ethical and multicultural issues are usually those involving conXicting rights and interests of diVerent individuals. In maternal–fetal medicine, for example, we may sometimes disagree about whose rights have the priority – a mother’s rights or her future child’s rights. For instance, whilst the proponent of abortion defends women’s auton- omous choice as a moral agent and their right to control their own body, the opponent may believe (on religious or other grounds) that the fetus is already a moral person and thus has rights that have to be taken into consideration. In most cases of maternal– fetal medicine this would often be the choice between respecting a pregnant woman’s right to decide what happens to her own body and protecting an innocent child from avoidable harm and damage. Besides abortion issues, rights and interest may also conXict when the woman’s actions and lifestyle (drugs, tobacco smoking, alcohol, sexually risky behaviour or unprotected sex) may directly or indirectly jeopardize the health of the fetus (Matthieu, 1996: p. However, in general these disagreements can usually be debated – if not always conclusively resolved – within a shared ethical framework that in itself accepts that all individuals have some universal and equal rights.