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Major depression is seen more frequently in women due to several factors discount aceon online american express blood pressure medication valsartan, such as hormonal differences order online aceon arteria3d viking pack, great stress cheap aceon american express blood pressure medication by class, or simply a bias in the diagnosis buy cheap aceon 4mg heart attack demi lovato mp3. There is also a higher incidence in those who have no close interpersonal relationships or are divorced or separated. Many studies have reported abnormalities in serotonin, norepinephrine, and dopamine. Other risk factors include family history, exposure to stressors, and behavioral reasons, such as learned helplessness. Presenting Symptoms Depressed mood most of the day Anhedonia during most of the day Significant weight loss (>5% of body weight) Insomnia Psychomotor agitation or retardation Fatigue or loss of energy nearly every day Feelings of worthlessness or guilt Diminished ability to concentrate Recurrent thoughts about death Physical Examination. Usually within normal limits; however, may find evidence of psychomotor retardation, such as stooped posture, slowing of movements, slowed speech, etc. May also find evidence of cognitive impairment, such as decreased concentration and forgetfulness. May also include: Psychotic features: worse prognosis Atypical features: increased weight, appetite, and sleep Treatment. Must first secure the safety of the patient, given that suicide is such a high risk. Individual psychotherapy is indicated to help the patient deal with conflicts, sense of loss, etc. Another form of therapy is cognitive therapy, which will change the patient’s distorted thoughts about self, future, world, etc. Differential Diagnosis Medical disorders: hypothyroidism, Parkinson’s disease, dementia, medications such as hypertensives, pseudodementia, tumors, cerebrovascular accidents Mental disorders: other mood disorders, substance disorders, and grief 5 Schizophrenia and Other Psychotic Disorders Learning Objectives List the diagnostic criteria and treatment approaches to schizophrenia and other psychotic disorders Schizophrenia Definition. Schizophrenia is a thought disorder that impairs judgment, behavior, and ability to interpret reality. Schizophrenia has been associated with high levels of dopamine and abnormalities in serotonin. Because there is an increase in the number of schizophrenics born in the winter and early spring, many believe it may be viral in origin. Schizophrenia is more prevalent in low socioeconomic status groups, either as a result of downward drift or social causation. Hospitalization is usually recommended for either stabilization or safety of the patient. If you decide to use medications, antipsychotic medications are most indicated to help control both positive and negative symptoms. The suggested psychotherapy will be supportive psychotherapy with the primary aim of having the patient understand that the therapist is trustworthy and has an understanding of the patient, no matter how bizarre. Differential Diagnosis Substance-induced: Psychostimulants, hallucinogens, alcohol hallucinosis, barbiturate withdrawal, etc. Epilepsy: temporal lobe epilepsy Other psychotic disorders: schizoaffective, schizophreniform, brief reactive psychosis, delusional disorder Malingering and factitious disorder: must assess whether the patient is in control of the symptoms and whether there is an obvious gain Mood disorders: Look at duration of mood symptoms; these tend to be brief in schizophrenia. Personality disorders: Schizotypal, schizoid, and borderline personality disorders have the most similar symptoms. Psychologic components include worry that is difficult to control, hypervigilance and restlessness, difficulty concentrating, and sleep disturbance. Psychodynamic theory posits that anxiety occurs when instinctual drives are thwarted. Behavioral theory states that anxiety is a conditioned response to environmental stimuli originally paired with a feared situation. The symptoms are severe enough to interfere with one’s ability to function in social or occupational activities. Characterized by the syndromes of delirium, neurocognitive disorder, and amnesia, which are caused by general medical conditions, substances, or both. Very young or advanced age, debilitation, presence of specific general medical conditions, sustained or excessive exposure to a variety of substances. Presenting Symptoms (Key Symptoms) Memory impairment, especially recent memory Aphasia: failure of language function Apraxia: failure of ability to execute complex motor behaviors Agnosia: failure to recognize or identify people or objects Disturbances in executive function: impairment in the ability to think abstractly and plan such activities as organizing, shopping, and maintaining a home 9 Dissociative Disorders Learning Objectives Define depersonalization and derealization Describe the presentation of dissociative amnesia with and without fugue Recognize dissociative identity disorder Dissociation Dissociation is the fragmentation or separation of aspects of consciousness, including memory, identity, and perception. Some degree of dissociation is always present; however, if an individual’s consciousness becomes too fragmented, it may pathologically interfere with the sense of self and ability to adapt. Presenting complaints and findings of dissociative disorders include amnesia, personality change, erratic behavior, odd inner experiences (e. The risk that a stressor will cause an adjustment disorder depends on one’s emotional strength and coping skills. Extremely common; all age groups Onset is typically within 3 months of the initial presence of the stressor, and it lasts ≤6 months once the stressor is resolved. If the stressor continues and new ways of coping are not developed, it can become chronic. Complaints of overwhelming anxiety, depression, or emotional turmoil associated with specific stressors Associated Problems. Social and occupational performance deteriorate; erratic or withdrawn behavior Treatment. Brief psychotherapy to improve coping skills Pharmacotherapy: Anxiolytic or antidepressant medications are used to ameliorate symptoms if therapy is not effective. Depressed mood Anxiety Mixed anxiety and depressed mood Disturbance of conduct Mixed disturbance of emotions and conduct 11 Substance-Related and Addictive Disorders Learning Objectives Describe the neuroanatomy of substance-related and addictive disorders Present the epidemiology of addictive disorders Describe the behavioral and pharmacologic approaches to treating addicts Substance Abuse and Addiction Definitions Substance use disorder: negative behavioral, cognitive, and/or physiologic symptoms due to use of a substance, yet use continues despite these adverse consequences Intoxication: reversible substance-specific syndrome due to recent use of a substance Withdrawal: substance-specific behavioral, cognitive, and/or physiologic change due to the cessation or reduction in heavy or prolonged substance use Physical and Psychiatric Examination Substance abuse history: includes the substance(s) used, dosage(s), effects, duration and social context of use, and prior experiences with substance detoxification, rehabilitation, and relapse prevention Medical history: includes complications of substance abuse Psychiatric history: includes other primary psychiatric diagnoses and past treatments Mental status examination: includes signs of substance-induced disorders Physical examination: includes signs of substance use Risk Factors/Etiology Family history: Biological sons of alcoholics are more likely to develop alcoholism than the general population. Physiology: Individuals who are innately more tolerant to alcohol may be more likely to develop alcohol abuse. Affirmative answers to any 2 of the following questions (or to the last question alone) are suggestive of alcohol abuse: Have you ever felt that you should cut down your drinking? Have you ever had a morning drink (eye-opener) to steady your nerves or alleviate a hangover? Blood Alcohol Levels and Effects on Behavior Blood Alcohol Behavioral Effect Level 0. Substances of Abuse Signs and Signs and Treatment of Substance Symptoms of Symptoms of Intoxication Intoxication Withdrawal 1. Anxiety, autonomic antipsychotics, tremulousness, hyperactivity, benzodiazepines, headache, 1. Amphetamines, weight loss, vitamin C to increased cocaine papillary promote appetite, dilatation, excretion in depression, perceptual urine, anti- risk of suicide disturbances hypertensives 1. Depression, steroids psychosis, heart abstinence risk of suicide problems, liver problems, etc. Impaired motor coordination, slowed sense of time, social withdrawal, conjunctival 1. None dissociative antipsychotics, symptoms, benzodiazepines pupillary dilatation, tremors, incoordination 1.

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Create a 2 cm circular skin incision at the stoma site and bring the loop outside through this (Fig order 4 mg aceon mastercard arrhythmia triggers. Use the loop of bowel to occlude the stoma site best order for aceon blood pressure chart 2015, allowing reinsufflation of the abdomen discount aceon 4 mg without a prescription blood pressure chart man. The surgeon stands at the right side or between the legs if lithotomy position is used purchase aceon 8 mg visa hypertension young women. Place the monitors on the right and left side at the level of the patient’s shoulder. The transverse colon usually reaches the chosen stoma site on the abdominal wall; rarely the splenic or hepatic flexure will need to be dissected. Bring the greater omentum cephalad and detach it from the colon; usually an energy device is used to promote better homeostasis Fig. Fashion a circular Media; 2006, with permission ostomy site in the desired position. Gently grasp the transverse colon with a Babcock and bring it to the surface through this incision. Check hemostasis and orientation as previously the inferior lateral part of the sigmoid until the splenic flex- described. If the patient is in modified lithotomy position, the surgeon then can move in between the patient’s legs to facilitate the Sigmoid Loop Colostomy splenic flexure dissection. Place the monitor on left side of the skin circular stoma site, incising the fascia with at least a patient at the level of the patient’s hip/knee. Deflate pneumoperitoneum and in Trendelenburg position with left side up 30° to move the pull out the sigmoid colon. Reinsufflate the abdomen and small bowel out of the pelvis and expose the sigmoid colon confirm correct position of the stoma, hemostasis, and lack of traction or torsion on the mesentery. The construction Dissecting the Lateral Attachment of the Colon and maturation of the stoma follows a standard fashion and In many cases the sigmoid colon must be mobilized from its can be totally diverting stapled (open proximal end and cre- lateral peritoneal attachment to achieve ideal stoma site loca- ate a small vent on the distal end, taking care to double tion. In this case, place a 5 mm port in the left upper quadrant check proximal and distal orientation) or a simple loop or suprapubic location. New York: Springer Science + Business Media; 2006, with permission Sigmoid Colon Resection with End Colostomy Incision of the Mesocolon and Division (Hartmann’s procedure) of the Sigmoid Colon Ensure that colon can be mobilized to the anterior abdominal Room and Trocar Placement wall and create a window in the mesentery. The division of The room setup and trocar placement are the same as for the bowel can be done intracorporally with a linear endo- sigmoid colostomy, described above. Position the patient scopic stapler, or, if the sigmoid colon is very mobile, the supine or in the modified lithotomy position, with both arms stapler can be used outside the cavity (Figs. After dividing the bowel, divide the mesentery with a vas- Place the monitor on left side of the patient at the level of the cular linear stapler or an energy device. Place the patient in Trendelenburg posi- matured and usual fashion, and the distal colon can be matured tion with left side up 30° to move the small bowel out of the as a mucous fistula or the distal end can be stapled and left in pelvis and expose the sigmoid colon. Establish pneumoperitoneum through the umbilicus using a modified Hassan’s technique. Place the second port at the Exteriorization of the Proximal Sigmoid Colon stoma site and the third port contralateral to the stoma site. In Pull the proximal segment through the ostomy site, resect if case of extensive adhesions, the contralateral port facilitates desired, and mature the stoma as previously described dissection of those adhesions. Identification of the Ureter The identification of the ureter can be facilitated by insert- Hartmann’s Take Down ing ureteral stents or by beginning the incision of the peri- toneum cephalad toward the origin of the inferior mesenteric Room and Trocar Placement (Figs. Sweep the vessels ventrally away from the preaortic Position the patient supine or in the modified lithotomy with hypogastric plexus (which is swept dorsally to prevent both arms tucked. The surgeon stands at the right and identify and protect the gonadal vessels and the ureter side of the patient. Place the patient in Trendelenburg 64 Laparoscopic Stoma Construction and Closure 609 Fig. New York: Springer Science + Business Media; 2006, with permission position with left side up 30° to move the small bowel and create a purse string suture and place the anvil of a 29 cm expose the sigmoid colon. Create pneumoperitoneum through a site away from the Stoma Mobilization old incision, usually through the right upper abdomen. Gently irrigate the rectum with a soft rubber catheter with Under direct visual guidance using sharp or energy device, warm saline solution. Mobilize the stoma in the usual fash- lyse midline adhesions and place the supraumbilical tro- ion from outside the abdomen. New York: Springer Science + Business Media; 2006, with permission around a 5-mm trocar that can be removed without further Dissecting the Rectal Stump closure at the end. Additional 5-mm trocars are usually Dissect the rectal stump free of adhesions or any small bowel placed in the right iliac fossa and right upper abdomen as loops to ensure a safe stapled anastomosis. The rectal Mobilize the splenic flexure and take down the transverse stump is then circumferentially mobilized for 3–5 cm from colon to ensure adequate length and free tension anastomo- the surrounding pelvic tissues. The use of an energy device is recommended as it pro- should be resected to ensure anastomosis of the descending vides excellent hemostasis. This mobilization proceeds as colon to the rectum when dealing with diverticular disease. If using a rigid or flexible sigmoidoscope, direct visualization of the anastomosis can be done. Postoperative Care Whenever an ostomy is created, apply a transparent ostomy pouch in the operating room to permit direct visualization of the quality of the mucosa of the stoma during the postopera- tive period. To ensure the viability of the stoma three techniques can be used: (1) direct vision with a anoscope, (2) gently insert the blunt end of a glass blood drawing tube (with the stopper removed) and shine a light through this to inspect the mucosa below the fascia, and (3) use the same glass tube and insert a bronchoscope into the tube to evaluate the mucosa above and below the fascia. If there is any doubt as to the viability of the mucosa below the fascial layer, revise the stoma. New York: Springer Science + Business Media; 2006, with permission • Necrosis • Parastomal hernia • Prolapse Performing the Anastomosis • Skin dermatitis from intestinal content leakage Before proceeding with the anastomosis, make sure that the descending colon can be brought down to the ideal place of anastomosis without tension. Then insert a 29-cm circular General Complications stapler through the rectum and pass the spike through the stump. Double check for lack of tension • Wound infection and appropriate orientation (lack of rotation). The anastomo- • Port site bleeding sis is better viewed from the lateral port site. New York: Springer Science + Business Media; 2006, with permission 64 Laparoscopic Stoma Construction and Closure 613 Fig. New York: Springer Science + Business Media; 2006, with permission 64 Laparoscopic Stoma Construction and Closure 615 Fig. New York: Springer Science + Business Media; 2006, with permission 64 Laparoscopic Stoma Construction and Closure 617 Fig. New York: Springer Science + Business Media; 2006, with permission 64 Laparoscopic Stoma Construction and Closure 619 Fig.

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Soot in the mouth or nose order aceon cheap blood pressure medication coreg, stridor purchase discount aceon line blood pressure medication start with l, wheezing 8mg aceon mastercard prehypertension due to anxiety, altered mental status discount aceon online amex blood pressure medication muscle weakness, burned nasal hairs, and burns involving closed spaces are all clues to impending pulmonary and laryngeal edema. Shock occurs not only from direct skin loss but also from release of a host of mediators that cause diffuse capillary leak for the first 18–24 hours. Serious capillary leak occurs when the percentage of serious body surface area burn >20–25%. Altered mental status, dyspnea, headache, and chest pain are clues to severe carbon monoxide poisoning. The “Rule of Nines” is used to determine the body surface area that has been burned, and thus assess fluid resuscitation needs: Head and arms: 9% each Chest, back, and legs: 18% each Patchy burns can be estimated by using one hand’s width as an estimate of 1% of body surface area burned. Circumferential burns are critical in the assessment because as they heal, they tighten and cut off circulation, leading to limb compromise and the need for escharotomy. Chest x-ray and bronchoscopy help determine the exact extent of respiratory injury when it is uncertain. Bronchoscopy can reveal severe thermal injury to the lungs even when the initial chest film is normal. If patient has signs of severe respiratory injury, the first step is to intubate before more severe laryngeal edema can occur and make the intubation difficult. If carboxyhemoglobin level is significantly elevated (>5–10%), administer 100% oxygen. Use Ringer’s lactate as the preferred fluid; give 50% of the fluid in the first 8 hours, 25% in the second 8 hours, and 25% in the final 8 hours. Exertional disorders vary from mild heat cramps to more severe heat exhaustion to potentially lethal heat stroke. Nonexertional disorders are malignant hyperthermia and neuroleptic malignant syndrome. This is a mild exertional disorder that can happen to any healthy person who develops fluid and electrolyte depletion. Patient develops painful muscular contractions lasting a few minutes, with muscle tenderness present. There may be mild neurologic symptoms such as headache, nausea, and anxiety, but severe confusion is rare. Death is very unlikely, but the disorder can progress to heat stroke if not treated. Patient has lost the ability to remove heat from the body because of an impaired ability to sweat; 50% of patients retain some capacity to sweat but in insufficient amounts to keep up with heat generation. Body temperature may become severely elevated (>41 C), resulting in confusion, disorientation, nausea, blurred vision, and seizures. Treatment for young athletes with exertional heat stroke is immersion in ice water. This is a nonexertional heat disorder occurring as an idiosyncratic reaction to an anesthetic agent such as halothane or succinylcholine. This is an idiosyncratic reaction to a wide variety of phenothiazines or butyrophenones such as haloperidol. It often occurs in association with alcohol intoxication, particularly in the elderly. The most common symptoms of severe hypothermia are related to the central nervous system. Other complications include metabolic acidosis, respiratory acidosis, kidney injury, and hyperkalemia. Most patients respond well to common-sense treatment such as a warm bed, bath, or heated blanket. Use caution, though, because overly rapid rewarming can cause arrhythmias; if life-threatening arrhythmias occur, it is important to continue resuscitative efforts until body temperature >35 C. Clinical Recall A 65-year-old woman is brought to the emergency department after a fall in the shower. On examination of the eye, there is mild dilation of the right pupil with evidence of papilledema in both eyes. Which of the following would not be considered in the management of this condition at this time? Nonionizing radiation is less destructive to tissue and causes injury primarily as burns. To give a sense of scale, mortality is almost zero with <2 Gy (or Sv) of exposure. Common sites of radiation injury include the following: Bone marrow: As little as 2–3 Gy (200–300 rad) can depress lymphocyte count. Neutrophils are the next most sensitive cell, while erythrocytes are the least sensitive. Long-term, leukemia is the earliest and most common cause of cancer from radiation exposure. Overall, infection and bleeding from depressed bone marrow function are the most common causes of death in acute exposure. Gonads: 2−3 grays result in temporary aspermatogenesis, while 4−5 grays can make men permanently sterile. Also, the rapidly reproducing intestinal lining ulcerates, leading to bleeding and infection later. Other common sites of radiation injury: the skin, salivary glands, respiratory epithelium, and thyroid glands Treatment. Alcohol and drug use are strongly associated with an increased risk of death by drowning. Muscular exhaustion, head and spinal trauma, or acute myocardial infarction are predispositions to drowning and near drowning. Drowning from aspiration of water can be divided into 2 types: Freshwater (hypotonic) alters pulmonary surfactant, resulting in unstable alveoli which then collapse. The hypotonic water is absorbed into the body, leading to acute hypervolemia, hemodilution, and intravascular hemolysis. Seawater (hypertonic) draws water out of the body into the lung, causing systemic hypovolemia and hemoconcentration. The lungs become even more heavy and fluid-filled because the surfactant is essentially washed out. Only the presentation of near drowning is important to discuss because drowned victims are dead. Cyanosis, coughing, and signs of pulmonary edema, such as tachypnea, tachycardia, and blood-tinged sputum are common. Arterial blood gases show hypoxia and hypercarbia, as well as metabolic acidosis from anaerobic metabolism. Endotracheal intubation as needed Supplemental oxygen Positive pressure mechanical ventilation as needed After removal from water, the most important initial step is to establish an adequate airway.

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