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CARE PLAN ON HYPONATREMIA
1.INTRODUCTION: For my clinical experience I was posted in Medical ward in Muthu kumaran Medical College and Hospital as part of Advanced Nursing Practice requirements. Mrs Suganthi, 79 years old brought to the hospital by her daughter with increased confusion . She was cooperative throughout my study. So, I selected Mrs. Suganthi who was suffering from headache, loss of appetite and muscle cramps care plan .
Name of the patient
2 nd standard
Date of Admission
2.1. Chief Complaints: Patient brought to hospital with increased confusion .Two weeks before she was normal. Two days before she had a complaints of loss of appetide , headache, Muscle cramps and also cold hands and feet. She is known hypertensive patient.
3. HISTORY 3.1 Past Medical Illness: Mrs. Suganthi is known case of hypertensive past 5 years. The client has also had a history of severe head ache and giddiness 2 months back got admitted in the hospital her BP was 150/100 mm/hg. She was on tab. Atenanol . after admission they changed in to Tab. Bendroflumethazide 2.5 mg OD 3.1.1 Present medical illness: Mrs. Suganthi brought to hospital with increased confusion .Two weeks before she was normal. Two days before she had a complaints of loss of appetide , headache, Muscle cramps and also cold hands and feet. She is known hypertensive patient 3.2 Past surgical history: There is no history of past surgical history. 3.2.1 Present surgical history: There is no history of present surgical history. 3.3 Family History: There is no history of consanguineous marriage. There is no history of hypertension and diabetes mellitus.
There is no history of communicable disease like Tuberculosis and leprosy.
3.3.1 Family Composition: S.
Married 4 th std
Married 2nd std
Son in law
Married 12th std
yrs 2 3 4.
3.3.2 Pedigree Chart :
Mr. Kannan 82 yrs
Mrs. Kavitha 45 yrs
Mr. Praveen 18 yrs
Mrs. Suganthi 79 yrs
Mr. Sugumaran 48 yrs
Ms. Preethi 15 yrs
3.4. Personal History: Mrs . Suganthi is non vegetarian, but she likes to eat vegetarian food. She takes adequate rest and sleep daily. She is not allergic to any kind of food or drugs. She speaks Tamil . 3.5 .Socioeconomic background: Mr. Sugumaran is the breadwinner of her family. Mrs Suganthi lives in a own house and in a nuclear family. Her house is well ventilated and lighted. The water and electricity facility are adequate. Good sewage disposal facility was available. There is no pet animals or garden in her home. 3.6. Elimination Pattern: Elimination pattern is good only. 3.7. Sleep Pattern Mrs. Suganthi sleeping pattern is little bit poor during night. She use to take a nap in the noon time. 3.8. Martial History She got married 42 years back 3.9. Menstrual history Attained puberty at the age of 14. 3.10. Diet History Mrs. Suganthi is non vegetarian, but she likes to eat vegetarian food. She takes adequate rest and sleep daily. There is no allergic to food.
Diet chart for 24 hrs Time
Sambar Veg soup
12 small 1.1
4. PHYSICAL ASSESSMENT:
4.1 HEAD TO FOOT ASSESSMENT: 4.1.1 GENERAL APPEARANCE: Nourishment
Moderate body built
72 beats per minute
22 breaths per minute
150 /100 mm Hg
4.1.2 VITAL SIGNS:
97% Severe pain
4.1.3 ANTHROPOMETRIC MEASUREMENT: Height
4.1.4 MENTAL STATUS: Consciousness
increased in confusion,partially oriented
Dull and drowsy
Drowsy, not able to walk properly
4.1.6 SKIN CONDITIONS: Color
White in complexion
4.1.7 HEAD AND FACE: Scalp
No dandruff and pediculosis is present
Reacting to light
No discharges, normal in alignment
4.1.10 NOSE: External nose
No septal deviation
Dry and cracks
No bad smell
White in color, No dental caries
Range of motion
Symmetrical chest wall movements present
loss of appetite
4.1.13 THORAX: Chest 4.1.14 ABDOMEN:
Bowel sounds heard in all four quadrants.
Range of motion is restricted due Knee pain age related factor
Both the extremities are symmetrical
4.1.16 BACK AND SPINE:
No abnormality found.
4.1.17 GENITALIA :
4.1.18 ELIMINATIONS: Voiding
Colour of urine
4.1.19 RECTUM AND ANUS: Bowel elimination
passes stool one time a day
INFERENCE: Through this physical examination the following findings were identified.
Bowel sounds heard in all four quadrants.
Muscle cramps present.
Severe head ache also present
4.2 SYSTEMIC ASSESSMENT: 4.2.1 CENTRAL NERVOUS SYSTEM:
Confused and disoriented
4.2.2 CARDIO-VASCULAR SYSTEM: Inspection
symmetrical chest wall movements present.
S1 S2 heart sounds heard. No murmur. Heart rate: 72 beats per minute. Rhythm: Regular
Pulse rate: 84 beats per minute. Blood pressure: 150/100 mm Hg.
4.2.3 RESPIRATORY SYSTEM: Inspection
Respiratory rate: 22 breaths per minute. Symmetrical chest wall movements present.
Bilateral air entry present and NVBS heard.
No excessive air collection is present.
4.2.4 GASTRO-INTESTINAL SYSTEM: Inspection
No scar and abdominal distension
Bowel sounds heard in all four quadrants.
Pain over right lumbar region present.
Dullness over right lower abdomen present.
4.2.5 GENITO-URINARY SYSTEM: Inspection
There is no insertion of Foleys catheter
No murmurs on right and left side of the upper abdomen
There is no pain in the lumbar region.
Dullness over supra pubic region present.
4.2.6 MUSCULO-SKELETAL SYSTEM:
Edema present in the legs. Range of motion is restricted due to Acute mono arthritis . Both extremities are symmetrical.
Capillary refilling time is less than 4 seconds
4.2.7 INTEGUMENTARY SYSTEM: Inspection
Dry, pallor, no cyanosis and no lesions.
4.2.8 LYMPHATIC SYSTEM:
No lymph nodes enlargement
4.2.9 ENDOCRINE SYSTEM:
No thyroid gland enlargement
Severe head ache is present. Not fully oriented.
Dullness over supra pubic region present
5. INVESTIGATION: S.NO.
Complete blood count: TC
4500 – 11000
P50 – 70% E2 – 4%
P67% L 21% E6%
L20 – 30%
13.5 – 16.5 g/dl
0 – 15 mm/hr
Renal function test:
2 – 4 lakhs/minute
80 – 120 mg/dl
17 – 40 mg/dl
0.5 – 1.5 mg/dl
1.6 7 mg/dl
135 – 145 mEq/L
4.5 – 5 mEq/L
Liver function test:
10– 40 U/L
5– 40 U/L
5 - 8 g/dl
3.5 – 5 g/dl
6. MEDICATION CHART: Drug name
route 1g / bd / IV
Cefoperazone is an
antibiotic. It works
from an infection
by preventing the
formation of the
bacterial protective covering which is
vitamin K levels.
essential for the
survival of bacteria. Sulbactum is a betalactamase inhibitor which reduces resistance and
A decrease in the blood clotting protein prothrombin.
Increased risk of bleeding
red blood cells).
due to clotting
Cefoperazone against bacteria.
inflammatio n of the large intestine.
1g / BD/ IV
Paracetamol has a
problems. Severe hepatic
analgesic effect that
is mediated through
exists about its
primary site of action, which may be inhibition of prostaglandin (PG) synthesis or through an active metabolite influencing cannabinoid Inj. Pantaprozole
40mg / bd / IV
receptors. Pantoprazole is
Pantoprazole is co
used to treat certain
patients with a
(such as acid
reflux). It works by
the drug itself, to
components of the
amount of acid your
This medication reli benzimidazole .
eves symptoms such
as heartburn, difficulty
Low amount of
in the blood.
a type of
kidney inflammatio n called interstitial nephritis.
suba cute cutaneous lupus erythematos us.
syste mic lupus erythematos us, an autoimmune disease.
2.5 mg oral
e, a thiazide
excess water from
the body by
increased activity of
often you urinate
(pass water) and
also widens the
cholesterol. a type of joint disorder
blood vessels which helps to reduce blood pressure. It
Feeli Advised ng thirsty, the with a dry patient to mouth. take lot Feeli ng or being sick (nausea or vomiting) Sto mach pain. Diar rhoea.
of water to prevent dehydrati on. Advised to take high
Loss of appetite.
from the distal
acid in the
blood called adequate gout. Seve rest low amount re joint pain. of magnesium Feeli ng dizzy in the and faint. blood. high
amount of calcium in the blood.
low amount of sodium in the blood.
Advised Con stipation
9. NURSING PROCESS APPLICATION 9.1 Nursing Diagnosis: 1. Acute pain related to inflammation of joint as evidenced by reports of pain. 2. Impaired physical mobility related to neuromuscular skeletal impairment evidenced by inability to move purposefully within the physical environment. 3. Risk for infection related to septic arthritis as evidenced by client says having temperature. 4. Impaired skin integrity related to surgical repair as evidenced by client says that itching and numbness present near to surgical site. 5. Activity intolerance related to joint pain. 6. Self care deficit related to musculoskeletal impairment as evidenced by inability to carry out proper personal hygiene. 7. Deficient knowledge related to lack of exposure as evidenced by frequently asking questions. 8. Fear and anxiety related to disease progress as evidenced by patient’s verbalization. 9. Imbalanced nutrition less than body requirements related to loss of appetite. 10. Severe pain associated with distention of tissue by the inflammatory process. 11. Impaired Physical Mobility associated with skeletal deformities, pain, discomfort, and decreased muscle strength.
9.2 Nursing care plan
Assess ment Subject ive data: Patient says that she is having increas ed body tempera ture
Risk for infection related to traumatized tissue as evidenced by client says having temperature
Objecti ve data: Vitals checke d tempera ture is 99’f
. Subject ive data: Patient
Monitor temperature every hour for increase in temperature. Keep the To reduce the windows temperature open, and use the fan. Sponge the patient with running tap water (tepid sponging). Eliminate excess clothing and covers.
Monitored temperature hourly and it maintains 99’f to 100’f.
Increased body temperature will destroy the cells.
Windows kept opened and fan also switched on.
Helps to cool the atmosphere.
Tepid sponging given.
It helps to bring down the Removed excess temperature. clothing’s. Exposing skin to room air decreases Oxygen kept ready warmth and with mask increases evaporative Ready oxygen cooling therapy. Hyperthermia Tab. Dolo 650 increases the given per orally metabolic demand for oxygen. Antipyretic medications lower body temperature. Discuss patient’s fatigue and identity activities that
Discussed to the patient.
It helps in planning the care.
Patient’s body temperatur e returned to normal temperatur e 98.8’f.
express that she is not able to do his daily activitie s.
Impaired physical mobility related to neuromuscular skeletal impairment evidenced by inability to move purposefully within the Objecti physical ve environment. data: Patient looks dull and weak.
produce fatigue. To improve activity within her capability.
Monitored vital signs, checked for pallor.
Monitor limitations, provisions for activity, signs and symptoms of fatigue Assisted the while doing patient in her daily activities. living activities. Assist patient with self-care activities of daily living. Encourage adequate rest and passive exercises. Encouraged adequate dietary improvement.
Teaches the patient passive exercise and encouraged to do it own. Advised to take nutritious diet.
Provide baseline for increasing activities and fatigue could be due to circulatory collapse. It helps to improve her activities. Helps to conserve energy. Helps to meet the metabolic needs
Improved the daily living activities.
Subject ive data: Patient express ed that she is not feeling to take food.
Objecti ve data: Patient looks dull
Assess for recent changes in physiological status that may interfere with nutrition. Imbalanced nutrition less than body requirements related to loss of appetite .
To improve the nutritional status and improve the appetite.
Discourage fluid intake during meals and allow after the meal is completed. Encourage to take protein rich diet Split the meals into six small units instead of three large ones.
Provide energy supplements as per Dr’s advise
Assessed the physiological status of nutrition by obtaining the eating pattern. Instructed the patient not to take fluid in between the meals. Encouraged to take her take rich protein diet Advised to split the meals into six small units.
Patient is on vitamin tablets.
The consequences of malnutrition can lead to a further decline in the patient's condition. In-between fluid intake reduces food intake.
It helps to promote eating habit. The small units taken in regular intervals reduce the fullness feeling and the risk of vomiting. These supplements have been proven to increase weight
Patient consumes sufficient amount food.
Subject ive data: Patient express ed that she is having numbne ss.
Impaired skin integrity related to surgical repair as evidenced by client says that itching Objecti and numbness ve present near to data: surgical site. She is scratchi ng near to surgery site
Subject ive data: Patient express ed that she is having so much of questio ns about disease
Assess for any skin discoloration near to the surgical site. To improve the skin integrity
Assess for any wrinkles in the bed cover. Assess for the position which is suitable for the patient.
Bed sheet is tucked properly without wrinkles.
To prevent pressure sore
Patient Position is changed often
To improve the circulation
Improve d the circulati on
Early ambulation is preferred
Assess for early ambulation
Future expectation about ambulation Fear and anxiety related to disease progress as evidenced by patient’s verbalization
Massage that area To increase blood slightly to improve circulation the blood circulation
To reduce the anxiety and fear about the disease
Encourage the patient to continue active exercise for the joints Identify the signs and
Internal fixation devices can ultimately compromise the bone’s strength it can be removed later stage Prevents joint stiffness, contractures, and muscle wasting, promoting earlier return to independence in
Explained about the surgery as well as when the implant can be removed. Improve the mobility
Discoloration of skin watched to prevent complications
Patient kept comfort able position
symptoms for patient for further treatment. Recommend for proper clothing Objecti ve data: She looks dull
Subject ive data: Patient express ed that not able to move the legs its heavy
Objecti ve data: Edema is
activities of daily living Prompt intervention may reduce the severity of complications such as infection or impaired circulation
Grooming is encouraged to kept comfortable To improve muscle strength
Discuss the dietary needs Facilitates dressing and grooming activities.
Risk for neurovascular dysfunction related to tissue trauma.
Assess capillary return, skin color, and warmth To improve distal to the neurovascular fracture. function Investigate tenderness, swelling, pain on dorsiflexion of the foot Assess the entire length of injured extremity for swelling or edema formation. Evaluate the presence and quality of
A low-fat diet with adequate quality protein and rich in calcium promotes healing and general well-being. Return of color should be rapid (3–5 sec). White, cool skin indicates arterial impairment. Cyanosis suggests venous impairment. There is an increased potential for thrombo phlebitis and pulmonary emboli in patients immobile for several days. An increasing circumference of the injured extremity may suggest general tissue swelling or edema but may reflect hemorrhage. A decreased or absent pulse may
Assessed for the Capillary return
Early ambulation is encouraged
Assessed for the extremity is for the edema
Checked the peripheral pulse for circulatory status
Vitals checked and recorded
Subject ive data: Patient says that she is not able to do work.
Objecti ve data: Very difficult to move one place to another
peripheral pulse distal to injury via palpation or Doppler.
Self care deficit related to musculoskelet al impairment as evidenced by inability to carry out proper personal hygiene.
Monitor vital signs. Note signs of general pallor, cyanosis, cool skin, changes in mentation. Encourage them to do their daily activity Encourage the patient take a good fibre and protein rich diet Encourage the patient to take adequate water to prevent hydration Encourage the patient to divert her mind from thinking about disease
reflect vascular injury and necessitates immediate medical evaluation of circulatory status. Inadequate circulating volume compromises systemic tissue perfusion. To improve the self confidence
To improve the elimination pattern To prevent dehydration
Divert her mind to over come out of disease
Encouraged them to do their daily activities Encouraged the patient to take rich in fibre diet Encouraged the patient to take plenty of water to prevent hydration Provided musical therapy to divert her mind .
10. NURSING THEORY APPLICATION: LYDIA E. HALL NURSING THEORY: As Hall (1965) says; “To look at and listen to self is often too difficult without the help of a significant figure (nurturer) who has learned how to hold up a mirror and sounding board to invite the behaver to look and listen to himself. If he accepts the invitation, he will explore the concerns in his acts and as he listens to his exploration through the reflection of the nurse, he may uncover in sequence his difficulties, the problem area, his problem, and eventually the threat which is dictating his out-of-control behavior”. MAJOR CONCEPTS: The individual human who is 16 years of age or older and past the acute stage of a long-term illness is the focus of nursing care in Hall’s work. The source of energy and motivation for healing is the individual care recipient, not the health care provider. Hall emphasizes the importance of the individual as unique, capable of growth and learning, and approach. Health can be inferred to be a state of self-awareness with conscious selection of behaviors that are optimal for that individual. Hall stresses the need to help the person explore the meaning of his or her behavior to identify and overcome problems through developing self-identity. The concept of society/environment is dealt with in relation to the individual. Hall is credited with developing the concept of Loeb Center because she assumed that the hospital environment during treatment of acute illness creates a difficult psychological experience for the ill individual (Bowar-Ferres, 1975). Loeb Center focuses on providing an environment that is conducive to self-development. In such a setting, the focus of the action of the nurses is the individual, so that any actions taken in relation to society or environment are for the purpose of assisting the individual in attaining a personal goal. Nursing is identified as consisting of participation in the care, core, and cure aspects of patient care.
Four major concepts Explanation by Lydia H. Hall
Individual or person
The individual human who is admitted in hospital for treatment of “Acute glomerular Nephritis” focuses on nursing care in Hall’s work. The source of energy and motivation for healing is the individual care recipient, not the health care provider. Hall emphasizes the individual’s importance as unique, capable of growth and learning, and requiring a total person approach. Maintain ABC of the patient. Provide supplemental oxygen therapy to the patient. Do not deliver more than 2 lt. of oxygen per minute if person has history of chronic pulmonary diseases. Monitor for ABG value to assess the patient response to oxygen therapy. Continuous monitoring of vital signs should be done. Check for urine output of the client. Maintain nutritional status of the patient. Administer prescribed medication to the patient. Give psychological support to the patient and the relatives
Health can be inferred as a state of self-awareness with a conscious selection of optimal behaviours for that individual. Hall stresses the need to help the person explore the meaning of his or her behaviour to identify and overcome problems through developing self-identity and
maturity. Give comfortable position. Keep the patient warm and monitor temperature hourly. Administer intravenous fluids as ordered. Monitor urine output. Administer oxygen as ordered. 3
The concept of society or environment is dealt with
concerning the individual. Hall is credited with developing Loeb Centre’s concept because she assumed that the hospital environment during treatment of acute illness creates a difficult psychological experience for the ill individual. Loeb Centre focuses on providing an environment that is conducive to self-development. In such a setting, the focus of the nurses’ action is the individual. Any actions taken concerning society or the environment are to assist the individual in attaining a personal goal. Consult nutritionist for recommendations about diet. Provide psychological support Assist for daily living activities
Nursing is identified as participating in the care, core, and cure aspects of patient care. Take precautions to prevent nosocomial infections. Wash hands frequently.
Use aseptic techniques. Monitor the extent of fluid retention. Monitor daily weight of the patient. Determine the severity of oedema Watch for elevation in central venous pressure
10.1CONCEPTUAL FRAME WORK:
11. JOURNAL PRESENTATION: Name of the topic : Occurrence and relative risk of stroke in incident and prevalent contemporary rheumatoid arthritis Name of the Author : Holmqvist M, Gränsmark E, Mantel A, Alfredsson L, Jacobsson LT, Wallberg-Jonsson S, Askling J DOI: 10.1136/annrheumdis-2012-201387
Abstract Objective: In contrast with the wealth of data on ischaemic heart disease in rheumatoid arthritis (RA), data on stroke are scarce and contradictory. Despite the high clinical and aetiological relevance, there is no data regarding when (if ever) after RA diagnosis there is an increased risk. Our objective was to assess the risk of stroke (by subtype) in contemporary patients with RA, particularly in relation to time since RA diagnosis. Methods: One incident RA cohort diagnosed between 1997 and 2009 (n=8077) and one nationwide prevalent RA cohort followed at Swedish rheumatology clinics between 2005 and 2009 ((n=39 065) were assembled). Each cohort member was matched to a general population comparator. Information on first-time hospitalisations for stroke up to 2009 was retrieved from the Swedish Patient Register. HR and 95% CI were estimated using Cox models. Results: In prevalent unselected RA, the HR of ischaemic stroke was 1.29 (95% CI 1.18 to 1.41). In the incident RA cohort, the overall risk increase was small and non-significant (overall HR 1.11, 95% CI 0.95 to 1.30). When stratified by RA disease duration, an increased risk of ischaemic stroke was indeed detectable but only after 10 or more years since RA diagnosis (HR>10 years: 2.33, 95% CI 1.25 to 4.34). Risk of haemorrhagic stroke was increased in prevalent but not in incident RA. Conclusion: The magnitude of stroke risk is lower than for ischaemic heart disease in RA, and the evolvement of this risk from RA diagnosis may be slower. This suggests different driving
forces behind these two RA co-morbidities and has implications for the clinical follow-up of patients with RA. CONCLUSION: By doing this nursing case study I have learnt more about “ACUTE MONO ARTHRITIS” and I am able to give comprehensive nursing care to the client. The client also gained more knowledge about the disease and ways to get out of the discomfort. I can provide proper care and psychological support for this type of patients in future.
12. BIBLIOGRAPHY: 12.1 Book Refference:
Bare G. Brenda and Suzzane C. Smeltzer (2012), “Brunner and Suddarth’s Textbook of Medical and Surgical Nursing”, 12th edition, Philadelphia Lippincott Williams and Nilkins, 1314 – 1316.
Joyce Black, Jannatekanson Hawks (2005), “Textbook of Medical and Surgical Nursing”, 7th edition, Missouri Elsevier Inc., 1112 - 1114.
Lewis (2015), “A Textbook of Medical and Surgical Nursing”,7th edition, westline industries, New York, 781- 783.
Brunner and Siddharth’s (2009). Textbook of medical surgical nursing, edition 13th published by Lippincott publishers, Pg.no (216 – 234)
Joyee M Black and Hawks J.H. (2009). Medical and Surgical nursing clinical management for positive outcomes, edition 7th, Pg.no (2443 – 2477)
Lewis (2013). Medical – Surgical Nursing, edition 3rd, Elsevier publications, New Delhi, Pg.no (248 – 286)
Saunders (1977). Manual of nursing practice, 1st edition, published by W.B. Saunders, Pg.no (364 – 380)
American academy of orthopaedic surgeons, emergency, care and transportation of the sick and injured published by Jones and Barlett, 7th edition printed in1998, Pg.no (541 – 550)
Smeltzer C. Suzanna, Bare G Brenda, Brunner and Suddath, (2004). Text book medical surgical nursing,10th edition, Philadelphia, Pg.no (84 – 90)
Lgnatavicius D Donna, Workman Linda M. Misher Marry A, Medical Surgical Nursing – nursing approach. Vol – 1, edition 2nd, USA, Saunders company, 1995, Pg, no 102 – 103
Bourgeois, M. S., & Hickey, E. (2011). Dementia: From Diagnosis to Management – A Functional Approach. New York: Taylor & Francis.
Grifka, J., & Ogilvie-Harris, D. (2012). Osteoarthritis: Fundamentals and Strategies for Joint-Preserving Treatment. New York: Springer Science & Business Media.
Izzo, J. L., & Black, H. R. (2003). Hypertension Primer: The Essentials of High Blood Pressure. New York: Lippincott Williams & Wilkins.
Kilmartin, A. (2002). The Patient’s Encyclopaedia of Urinary Tract Infection, Sexual Cystitis and Interstitial Cystitis. Boston: Angela Kilmartin.
Moskowitz, R. W. (2007). Osteoarthritis: Diagnosis and Medical/Surgical Management. New York: Lippincott Williams & Wilkins.
12.2 Journal Refference: Maetzel, A., Mäkelä, M., Hawker, G., & Bombardier, C. (1997). Osteoarthritis of the hip and knee and mechanical occupational exposure--a systematic overview of the evidence. The Journal of rheumatology, 24(8), 1599-1607. Hart, D. J., & Spector, T. D. (1993). The relationship of obesity, fat distribution and osteoarthritis in women in the general population: the Chingford Study. The Journal of rheumatology, 20(2), 331-335. Wolfe, F., Altman, R., Hochberg, M., Lane, N., Luggan, M., & Sharp, J. (1994). Post menopausal estrogen therapy is associated with improved radiographic scores in OA & RA. Arthritis Rheum, 37(Suppl 9), S231. Hellgren, K., Smedby, K. E., Feltelius, N., Baecklund, E., & Askling, J. (2010). Do
rheumatoid arthritis and lymphoma share risk factors?: a comparison of lymphoma and cancer risks before and after diagnosis of rheumatoid arthritis. Arthritis and rheumatism, 62(5), 1252–1258. https://doi.org/10.1002/art.27402
12.3 Net Refference : http://www.aafp.org http://www.ncbi.nlm.nih.gov http://www.uptodate.com