* Primary tumors that metastasize to the brain: lung, breast, skin, kidney, GI; remember that 50% of brain tumors are from metastases

* Primary tumors that metastasize to liver: colon, stomach, pancreas, breast, lung

* Primary tumors that metastasize to bone: prostate, thyroid, testes, breast, lung, kidney

Myxedema coma:

Hydrocortisone should be given until concomitant adrenal insufficiency has been ruled out as the addition of T4 in the setting of adrenal failure can precipitate adrenal crisis on top of myxedema as increasing the basal metabolic rate by the addition of thyroid hormone will increase the breakdown of cortisol. If the body cannot adequately replace cortisol due to adrenal insufficiency, the patient will ultimately deteriorate. This patient, therefore, should be given both IV levothyroxine and IV hydrocortisone at this time and be admitted to the medical intensive care unit for further monitoring. If the random cortisol is not extremely low, then it is not helpful in diagnosis, and a stimulation test must be performed. Until the stimulation test is negative, the patient should continue to receive IV hydrocortisone, at least 100mg every 8 hours.

Bipolar disorder tx: Major side effects of lithium include CNS depression, heart failure, arrhythmias, hypercalcemia, hypothyroidism, pseudotumor cerebri, diminished renal concentrating ability, and serotonin syndrome. Lithium can affect the fetus, causing cardiac malformations and should not be given to sexually active females of reproductive age without careful benefit/risk analysis. Lithium also has several drug interactions. Some examples of these interactions include with amphetamines, caffeine, calcium channel blockers, loop diuretics, NSAIDS, opioids, SSRI's, TCA's, Tramadol, and thiazide diuretics.

Remembering all of this may not be easy, but remembering four major contraindications and one relative contraindication may help, these include:

Severe cardiovascular disease Hypovolemia or dehydration (impairs lithium excretion) Sodium depletion (impairs lithium excretion) Chronic renal disease (impairs lithium excretion) Relatively contraindicated in pregnancy (causes Ebstein's anomaly)

If you can remember these things, it will help you remember which drugs and diseases can cause further complications. You will remember that thiazide and loop diuretics cause hypovolemia and/or sodium depletion. NSAIDs affect lithium binding and excretion due to renal and cellular effects. Calcium channel blockers affect lithium indirectly as lithium is a cation similar to calcium. Lithium can cause cardiac dysrhythmias including repolarization changes sinus node dysfunction. This is why lithium is contraindicated in severe cardiac disease.

Other things to remember include:

Lithium inhibits iodine coupling and can cause hypothyroidism and goiter Lithium can cause hypercalcemia and elevated PTH Lithium causes a tremor that is quite common, possibly due to accumulation in the substantia nigra Lithium causes cognitive changes and sexual dysfunction (most common reason for nonadherence)

The goal of the treatment of bipolar disorder is to treat both depression and mania without worsening one of the phases. Mood stabilizers are the best medications to treat bipolar disorder as they are able to treat at least one phase of bipolar disorder (mania or depression) without worsening the other. Mood stabilizers include Lithium, valproic acid, carbamazepine, lamotrigine, and antipsychotics. Examples of atypical antipsychotics are quetiapine, risperidone, and aripiprazole. Anti-depressants such as SSRIs are not mood stabilizers and should not be used alone as they can worsen mania. In fact, placing a depressed patient on an antidepressant and precipitating a manic episode is often a cause for a new bipolar diagnosis. To get this question correct you needed to realize that all of the above medications, including the antipsychotics and antiepileptics, can be used for bipolar disorder while avoiding the use of antidepressants. CBT can improve symptoms and help in long-term management but is generally not as helpful when patients are acutely manic and psychotic.

Overall, the choice of medication generally depends on the state of the patient. Patients with known bipolar disorder who are manic need mood stabilization and the treatment of choice for severe mania remains lithium or valproate, usually with antipsychotic medication. The ultimate choice depends on side-effects (history of sensitivity to extrapyramidal symptoms), the age and sex of the patient (in women who may become pregnant avoid valproate), and comorbid conditions (in obesity avoid olanzapine, risperidone, and quetiapine due to their tendency to worsen weight gain and lipids). Remember that patients with chronic renal disease will not excrete lithium well and that patients with severe liver disease will not metabolize valproate well. Individual therapy, including cognitive-behavioral therapy (CBT), can also be helpful in the treatment of bipolar disorder and should be added to standard medical therapy.

In patients with severe bipolar depression, an antidepressant can be used carefully with the addition of a mood stabilizer, often quetiapine, though usually quetiapine or lurasidone is effective alone.

house md, 5x04 / 8x22.

chin up nerds 🫂❤️

i had to put my dog down today 💔💔💔💔💔💔 worst thing i have ever experienced

Hiiii do you have any more writings or musings about None? I was in your writing tag the other night and they came up a couple times but I'm not sure if I should be picturing a miqo'te or some sort of service animal/familiar lol

Hello! That's so fair, my Odette writings do not offer a lot of description for them! They do have their own tag [HERE] although not much is in it, currently. Some of the screenshots I'm including here and the writings which you've already seen! I'm very sorry for how rambling this is but None is where a lot of alts and relationships spawn from! None is neither a miqo'te nor a service animal (though I think they'd give a huff at the title)! None is the saddest creature in the whole world, a widower, Odette's favorite lil guy, Gerry's estranged step-parent, and a Lalafell:

A Lalafell ranger who makes their living guiding people through the Shroud. These days they are 'mostly' retired. They're well past their middle age and when they were younger they made a deal with sylphs. To be fleet-footed and quick and the best hunter. It came with some side effects:

They wear a hat to cover the ears. It's a bit silly to have two sets and, frankly, None doesn't wanna talk about it. They are stoic, pragmatic, and a bit of a hermit when they can afford it. None is a widower, their late wife was an duskwight woman named Aloutte, who was a widow herself with a young child; Geraldine. None and Gerry were never close and in the wake of Aloutte's passing that distant only grew. None and Odette met at the Menphina temple she was raised at. The Sisters there offer grief counseling and when Aloutte first fell sick she made them go to make the transition easier. A child at the time, Odette was obsessed from the moment they met. A pale shadow trailing after them. Where None failed with Gerry, they bonded with Odette. After Aloutte's passing None returned to the temple to live long term, some grievers need more support than others, they and Odette spent a lot of time together. They very much fill a uncle/aunt role for Odette; a trusted advisor who isn't the adults who raised her. When Odette took her vows and started to travel it was None who traveled with her, taught her basic outdoors skills, bought her Beauty and taught her how to care for chocobos. When Odette has to leave her flock of karakul to travel it is None she calls to care for them. Also, while Aloutte's loss and the grief that follows is very important to None as a character I feel it is important to note they were the saddest creature in the whole world before they knew the warmth of Aloutte's embrace! Sometimes you're just born with a heavy heart, you know? Because of how important they are to Odette. Odile... fucking hates their guts. Oooh, she hates their guts so much!!! The feeling is mutual and Odile and None have come to blows a few times. Something they both keep from Odette; None because they don't want to make her worry, Odile because she'll use the information to drive a wedge at some point. None also features in Odette's WoL AU, they're an honorary scion and spend most of their time with the other off-screen members. They spend time with Krile and Tatatru discussing lalafell things and I like to imagine that F'lhaminn and None have a lot to talk about. This is... pretty long so I will stop here! But I hope this satisfies some curiosity about None and thank you SO MUCH for asking about them!

sometimes i feel bad that i don't contribute to conversations with my grandmother because it is kind of a waste to not really talk to someone who could have a lot of cool stories and life experience to share but then i remember that any time i try to interject or share something she just talks over me or ignores what i say so. whatever

there is no diagnosis or amt of pain that justifies mistreating healthcare workers which i know is a radical take because nurses are just Mean Girls and always will Deserve It.

“im normally a nice person” see i am actually not believing you because if your frontline stress response is cruelty and trying to ruin peoples lives you might consider that you are a baseline piece of shit kinda person instead

Troy’s daughter apparently being called Tracy is so…

tag game: bold what applies to you

tagged by @thewolvesof1998 thank you 🥰

APPEARANCE: i’m over 5’5” // i wear glasses/contacts // i have blonde hair // i prefer loose clothing to tight clothing // i have one or more piercings // i have at least one tattoo // i have blue eyes // i have dyed or highlighted my hair // i have gotten plastic surgery // i have or had braces // i sunburn easily // i have freckles // i paint my nails // i typically wear make-up // i don’t often smile // i am pleased with how i look // i prefer nike to adidas // i wear baseball hats backwards

HOBBIES AND TALENTS: i play a sport // i can play an instrument // i am artistic // i know more than one language // i have won a trophy in some sort of competition // i can cook or bake without a recipe // i know how to swim // i enjoy writing // i can do origami // i prefer movies to tv shows // i can execute a perfect somersault // i enjoy singing // i could survive in the wild on my own // i have read a new book series this year // i enjoy spending time with friends // i travel during school or work breaks (if i can afford it) // i can do a handstand

RELATIONSHIP: i am in a relationship // i have been single for over a year // i have a crush // i have a best friend(s) i have known for ten years // my parents are together // i have dated my best friend // i am adopted // my crush has confessed to me // i have a long distancerelationship // i am an only child // i give advice to my friends // i have made an online friend // i met up with someone i have met online

AESTHETICS: i have heard the ocean in a conch shell // i have watched the sun rise // i enjoy rainy days // i have slept under the stars // i meditate outside // the sound of chirping calms me // i enjoy the smell of the beach // i know what snow tastes like // i listen tomusic to fall asleep // i enjoy thunderstorms // i enjoy cloud watching // i have attended a bonfire // i pay close attention to colours // i find mystery in the ocean // i enjoy hiking on nature paths // autumn is my favourite season

MISCELLANEOUS: i can fall asleep in a moving vehicle // i am the mom friend // i live by a certain quote // i like the smell of sharpies // i am involved in extracurricular activities // i enjoy mexican food // i can drive a stick-shift // i believe in true love // i make up scenarios to fall asleep // i sing in the shower // i wish i lived in a video game // i have a canopy above my bed // i am multiracial // i am a redhead // i own at least three dogs

tagging @satellitemp4 @jeeyuns @zahlibeth @diazblunt @leothil @alyxmastershipper if you guys fancy 💘

I want to fall inlove with you. I want to hold your hand and look at your eyes closely. See all of your happiness, sadness, pain and anger… see you working through it all and smiling bravely while your heart races… I want to love you. I want to love you for being exactly who you are and nothing more or less. I want to accept your highest of highs and your lowest of lows. I want to watch you control the need to possess me because you feel I might slip away as I battle my need to slip away out of fear of needing to possess you.. I want to make love to you in a home that screams every bit of our personalities , coming together in a beautiful clash of compliments of hard and soft… I want to love you… I want kiss your body while your in a deep sleep , bask in the glory of you being all mine and mine alone even away from you… I want to love you… I want to look at your eyes when we talk and watch them change with emotions and stop myself from kissing you because as much as I want to hear you talk I’m falling in-love with you for sharing you so honestly with me… I want to love you… I want to love you …

Last week was a lot. Mother's day was difficult.

The first half was good; had brunch at my partner's parents' house. But afterwards while I was still just chilling at their house, my little sister started sending me a lot of messages pushing me to come to Ma's Mother's Day dinner. A lot of talking about trying to reconcile w parents which is a very difficult situation I'm navigating by myself.

It was honestly very upsetting. I ended up starting to cry and had to leave his parents' place early.

I had work the next day but the whole thing was really plaguing my mind and I had to finish work early and have a talk W my boss about it. I took the rest of the week off.

Luckily I had therapy that week and got to discuss it. Also talking to my big bro about it helped, and talking to my partner about his thoughts on the situation. I'm so glad to have a partner that supports and understands me being NC w parents.

So far no contact has been working really well for me. I have never been more happy, safe, or felt so loved in my life. Even just thinking of introducing them back into my life makes me feel stressed out, and why would I want more stress in my life? Therapy really helped me feel more secure in my choice to remain NC.

I knew I needed to have a chat w my lil sis to discuss my relationship w parents and boundaries around it, so we tried to set up some possible times to hang. We were meant to do it yesterday but her husband was really mad at her for literally dropping 2 IKEA meatballs, and a knife at a restaurant over the weekend, and said she gave him a migraine, so she couldn't go (I do not see how those lead to that conclusion but whatever). I basically said the reasons he's mad are stupid, but fine if you feel like it's better to stay home then we can try tomorrow. Then she said she can't visit me tomorrow either bc he won't let her. (I hate her saying "he won't let me" as if he's her dad grounding and scolding her)

He forbade her from visiting me EVER (which apparently he has brought up to her before). After she did dinner and dishes, he said it was a prank.

I'm fucking PISSED. That's not a prank. That's emotionally abusing and attempting to isolate your partner. A prank is meant to be funny, harmless, and both people understand and enjoy the joke. A prank is not making someone distressed and then saying "jokes! I take it back!" When they're upset.

Anyways her husband is stupid and I'm happy I'm NC w both my parents and her shitty husband.

I want to gag lol I've seen someone saying cancer mars women are the freakiest and I'm crying 😂 like bruh barely men are decent and high-key vanilla.. yeah, cream pie, tiddies, and breeding kink are the freakiest I guess. Women with Aries, Scorpio, Capricorn, Aquarius and even Sagittarius will be there looking 😳 wasn't that included in the vanilla package or I'm missing something?!

can you please do a couple tag for me

my boy: pisces sun leo moon cancer rising

me: sagittarius sun sagittarius moon aries rising

thank you in advancee ❤️❤️❤️

🩶Ted and Robin🩶

what is your beef with cancers I need to know. I would be so happy to have your face buried in my tits but you've chosen beef instead

now hold on……… maybe we dont need to beef at all…..

So grateful I found a perfect career that lets my colleagues capitalize on my whack interests AND they WANT me to infodump to the entire team routinely

don' dweeblog

#the one mass fanon I do NOT buy is how the malpractice dept is found family. #have you. SEEN this show?????

i have seen this show and i can say without a doubt that the malpractice department is definitely found family. because i know what their families are like.