Christopher A Ross, M.D., Ph.D.

• Director, Division of Neurobiology
• Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0000303/christopher-ross

If recent sinonasal surgery has occurred anxiety 13 year old sinequan 75mg with mastercard, obtaining operative notes may be helpful anxiety 30 minute therapy buy sinequan 75 mg without a prescription. General information that is relevant includes a prior history of easy bruising or bleeding; a family history of such problems or known bleeding disorder; bleeding problems with previous surgeries or dental work; history of anemia anxiety upon waking sinequan 75 mg low cost, malignancy anxiety symptoms last all day discount sinequan 25mg on-line, leukemia anxiety fatigue sinequan 10mg on line, lymphoma anxiety symptoms head tingling cheap 25mg sinequan mastercard, or chemotherapy; other systemic illnesses; or recent trauma. Also consider vitamins such as vitamin E, and other supplements or herbs, many of which can promote bleeding. Rhinology 231 alcohol abuse can be related to coagulation disorders from impaired liver synthetic function as well as malnutrition and vitamin deficiencies; illicit intranasal drug use may be causative. In summary, awareness and treatment of systemic conditions may be required to obtain definitive effective management of epistaxis. It is essential to have a nasal speculum and headlight, Frazier tip suctions, and oxymetazoline (Afrin; Schering-Plough Healthcare Products Inc. If topical 4% cocaine is available, this is a very effective decongestant and anesthetic, used sparingly. Often, the otolaryngologist will need to first remove improperly placed or ineffective packing materials. Removal of clots with suction will facilitate identification of bleeding sites, using the equipment described above. Imaging Profuse bleeding in a maxillofacial trauma patient should be managed with emergent angiography. An injury to the extradural portion of the internal carotid cannot be controlled with nasal packs; most of these injuries probably exsanguinate in the field. Also, in recurrent or difficult-to-treat epistaxis, angiography may be diagnostic (to localize a bleeding source and guide definitive therapy such as ethmoid ligation) or therapeutic (to embolize an external carotid source). Bear in mind that hemoconcentration in the underresuscitated patient may yield laboratory results that do not initially reflect the degree of blood loss. Platelet function studies may be helpful, although results may not be rapidly available. Spontaneous mucosal bleeding typically occurs in patients with platelet counts 20,000. Specifics Localize the source, as described above, using oxymetazoline spray, suction, a nasal speculum, and/or nasal endoscopy. Most bleeds are anterior and can be treated effectively with topical vasoconstrictors and direct pressure and/or simple silver nitrate cautery sticks. If bleeding will not respond to this, nasal packing to place pressure over the bleeding site may be required. Gelfoam, Surgicel, with or without topical thrombin, or Floseal are among the absorbable products available that will not require removal but will dissolve with nasal saline administration. Rapid Rhino (Brussels, Belgium) products, which are covered with a procoagulant and contain an inflatable balloon, are also effective. Experience has shown that an effective removable pack should be left in place for 4 days to enable healing prior to removal. Any patient with packing in the nose should be placed on systemic antibiotics with good gram-positive coverage, such as cephalexin or clindamycin, for prophylaxis against toxic shock. This device has a balloon that is inflated in the nasopharynx and a second balloon that provides pressure intranasally, and effectively tamponades a posterior bleeding vessel. Any patient with a posterior pack requires hospital admission with continuous pulse oximetry. A patient failing or rebleeding following these maneuvers is usually sent for angiography and possible embolization. If unavailable, and/or the surgeon is confident that the feeding vessel is identifiable, clipping or cauterization of the sphenopalatine can be performed endoscopically; ligation of the internal maxillary system can be performed via a Caldwell-Luc approach and takedown of the posterior wall of the maxillary sinus; or anterior or posterior ethmoid artery ligation can be performed via an external incision. Recall the 24-12-6 mm rule to locate the anterior ethmoid, posterior ethmoid, and optic nerve along the orbital wall; however, there is substantial variation with these measurements. Rhinology 233 Other Treatments Therapy for the Osler-Weber-Rendu patient is a challenge. One should rule out pulmonary or intracranial vascular malformations, which may be life-threatening, with appropriate imaging. N Outcome and Follow-Up Ongoing management of underlying medical disorders may be preventive. The condition resolves with treatment; inadequate treatment may lead to disabling chronic disease. The otolaryngologist often sees patients who are inadequately treated or who have recurrent disease. Collection of mucopus during nasal endoscopy enables one to obtain data for culture-directed antibiotic therapy. Treatment is usually medical, in the absence of orbital or intracranial complications. Rhinosinusitis (all varieties) is reported to affect 31 million people in United States. An estimated 20 million cases of acute bacterial rhinosinusitis occur annually in the United States. N Clinical Signs and Symptoms A history of acute rhinosinusitis may be suspected based on the presence of major and minor factors. Major factors include facial pain or pressure, congestion or fullness, nasal obstruction, nasal discharge, purulence, or discolored postnasal drainage, hyposmia/anosmia, purulence in nasal cavity on exam, and fever. Minor factors include headache, fatigue, halitosis, dental pain, cough, and ear pain or ear pressure/fullness. The presence of two major factors, one major with two minor factors, or three minor factors strongly suggests the diagnosis. Fever is relatively specific to acute rhinosinusitis versus other forms of sinonasal disease. Other entities to be considered include allergic rhinitis exacerbation, unrecognized chronic rhinosinusitis, or rare nasal manifestations of systemic disease such as limited Wegener granulomatosis or sarcoid. Other causes of localized symptoms include severe periodontal disease or recurrent migraine, which may include throbbing localized headache as well as nasal congestion. N Evaluation the diagnosis is generally made on the basis of major and minor factors present by history in combination with objective exam findings. Physical Exam A full head and neck examination is performed, including a cranial nerve exam. Therefore, note is made of proptosis, periorbital edema, extraocular motility, tenderness, and meningeal signs. Assessment includes position of the septum, presence of mucosal edema, presence, location, and quality of mucus or purulence, and the presence and quality of polyps or masses. A calcium alginate swab (calgiswab) or suction trap can be easily used to endoscopically obtain a sample of any purulence from the sinus ostia or middle meatus for culture and sensitivities. Imaging the diagnosis of uncomplicated acute rhinosinusitis is generally made on history and exam. The presence of fluid or soft tissue density opacification of a paranasal sinus is diagnostic. Bone erosion or thickening, or the presence of a sinonasal mass suggests other than acute rhinosinusitis and will prompt additional workup. Disease of the middle meatus, infundibulum, frontal recess, anterior ethmoids and superior nasal cavity is not identifiable. Microbiology It is generally accepted that viral infection predominates for the first 10 to 14 days and then leads to sinus ostia obstruction. If symptoms persist beyond 7 to 10 days, bacterial infection is likely and antibiotics are indicated. The typical duration of therapy is 2 weeks, and 4-week courses are often necessary. Adult empiric therapy published guidelines recommend (a) amoxicillin/clavulanate (1. Caution should be used in patients with prostatic hypertrophy or poorly controlled hypertension. Topical nasal steroids have been recommended recently to help decrease inflammation, and do play a prophylactic role following resolution of symptoms in patients with recurrent disease. Occasionally, maxillary puncture is necessary to obtain material for culture and/or to relieve severe symptoms. A common indication for this is an immunocompromised patient on multiple recent antibiotics with an occluded sinus. N Outcome and Follow-Up Acute rhinosinusitis generally resolves with appropriate medical treatment. Rhinology 237 with symptoms again lasting less than 4 weeks and recurring four or more times per year. Meningitis is the most common intracranial complication from acute rhinosinusitis, often from sphenoid disease. Underlying factors such as allergies, cilia motility disorders, and immunodeficiency disorders should be considered in refractory patients. Chronic rhinosinusitis results in an estimated 24 million physician visits annually in the United States, 90% of which result in a prescription. Minor factors include headache, fatigue, halitosis, dental pain, cough, and ear pain or ear pressure or fullness. Two major factors, one major and two minor factors, or pus in the nose on nasal examination strongly suggests sinusitis, and treatment should be initiated. Differential Diagnosis Intranasal neoplasia, benign or malignant, may present similarly to inflammatory disease. Neoplasms include papillomas (inverting, cylindrical), squamous cell or adenocarcinomas, salivary tumors, sarcomas, mucosal melanoma, schwannomas, osteomas, angiofibroma, and ethesioneuroblastoma. Other entities to be considered include nasal manifestations of systemic disease such as limited Wegener granulomatosis, Churg-Strauss syndrome, sarcoid, tuberculosis, leprosy, or syphilis. Other causes of localized symptoms include severe periodontal disease or recurrent migraine, which may include throbbing localized headache as well as nasal congestion (primary care providers may label cephalgia as "sinus headaches," independent of the presence of active sinonasal disease). Rhinitis medicamentosa is common and patients do not always admit to use of nasal decongestants. In the immunocompromised patient, a high index of suspicion for invasive fungal rhinosinusitis is critical. In certain clinical situations, consider Churg-Strauss syndrome (vasculitis, asthma, eosinophilia), eosinophilic granuloma spectrum (Langerhans cell histiocytosis), T-cell lymphoma (formerly considered midline lethal granuloma), rhinoscleroma (caused by Klebsiella rhinoscleromatis), or rhinosporidiosis (caused by Rhinosporidium seeberi) endemic in India and Sri Lanka. N Evaluation Controversy exists with regard to definitions and diagnoses of all forms of rhinosinusitis. As listed above, certain major and minor factors, when present, can strongly suggest the presence of disease. It is important to exclude evidence of complicated sinusitis, such as orbital or intracranial extension of disease. Assessment includes position and integrity of the septum, presence of mucosal edema, presence, location and quality of mucus or purulence, and the presence and quality of polyps or masses. A calgiswab or suction trap can be easily used to endoscopically obtain a sample of any purulence from the sinus ostia or middle meatus for culture and sensitivities. The otolaryngologist possesses unique expertise in nasal endoscopy, and this procedure should be part of the exam of all patients presenting with sinonasal complaints. Consider olfactory testing (especially in patients who note hyposmia/ anosmia as a complaint), such as the Smell Identification Test (Sensonics, Inc. The presence of fluid or soft-tissue density opacification of a paranasal sinus is diagnostic. Bone erosion or thickening, or the presence of a sinonasal mass suggests other than acute (chronic) rhinosinusitis and will prompt additional workup. Fungal disease presenting as allergic fungal rhinosinusitis will appear as heterogeneous density. Evidence of expansile disease with bone thinning is seen with allergic fungal rhinosinusitis, mucocele, and low-grade neoplasms. Bony erosion should raise concern for malignancy, and is also seen with inflammatory disease such as Wegener granulomatosis. Fungi are ubiquitous; topical or systemic antifungals are not used unless tissue-invasive fungal infection is present. The role of virus in chronic rhinosinusitis is unclear and has not been well studied. Pathogenesis and Classification Etiology is multifactorial, involving environmental, local host, and general host factors. Pathogenic environmental factors include viral infection, pollution, smoking, and allergy. Smoking is the single most significant factor in recurrent disease; some prominent surgeons will not perform elective sinus surgery on smokers, knowing that disease will recur. Host factors include atopy, immune deficiency, mucociliary clearance problems such as ciliary dyskinesia or cystic fibrosis (probably even subclinical forms of chloride transporter dysfunction), airway hyperactivity, and reactivity to fungus.

Partial thickness Epidermis 1st degree Superficial 2nd degree Full thickness Dermis 2nd degree Deep 2nd degree Pale anxiety symptoms for no reason buy sinequan 10 mg without a prescription, slightly moist anxiety symptoms upon waking up generic 25mg sinequan with visa, less red anxiety quotes images order 25 mg sinequan overnight delivery. Subcutaneous tissue Hair Sebaceous Sweat gland follicle gland Pearly white or charred anxiety reduction techniques generic sinequan 10mg without prescription, parchmentlike anxiety symptoms for hours cheap sinequan 75mg free shipping, translucent (veins show through) anxiety 4 year old cheap sinequan 75 mg mastercard. Surgeons sometimes use these lines to make skin incisions; other times, they may use the natural skin folds. However, skin fold incisions also may conceal the scar following healing of the incision. Generally, humans have about 214 bones, although this number varies, particularly in the number of small sesamoid bones that may be present. Chapter 1 Introduction to the Human Body 9 Epiphysial capillaries 1 Perichondrium Periosteum Proliferating hyaline cartilage Canals, containing Hypertrophic capillaries, periosteal calcifying mesenchymal cells, cartilage and osteoblasts Thin collar of cancellous bone Cancellous endochondral bone laid down on spicules of calcified cartilage Primordial marrow cavities A. At 10 weeks Articular cartilage Bone of epiphysis Calcified cartilage Epiphysial (secondary) ossification center Outer part of periosteal bone transforming into compact bone Central marrow cavity Epiphysial ossification centers Proliferating growth cartilage Proximal epiphysial growth plate Sites of growth in length of bone Distal epiphysial growth plate Hypertrophic calcifying cartilage D. At birth Calcified cartilage Endochondral bone laid down on spicules of degenerating calcified cartilage Proliferating growth cartilage Diaphysis; growth in width occurs by periosteal bone formation Metaphysis Bone of epiphysis Articular cartilage E. Diaphysis elongation, formation of the central marrow cavity, and appearance of the secondary ossiication centers in the epiphyses. Types of Joints Joints are the sites of union or articulation of two or more bones or cartilages, and are classiied into one of the following three types. Fibrous joints include sutures (lat bones of the skull), syndesmoses (two bones connected by a ibrous membrane), and gomphoses (teeth itting into ibrous tissue-lined sockets). Cartilaginous joints include primary (synchondrosis) joints between surfaces lined by hyaline cartilage (epiphysial plate connecting the diaphysis with the epiphysis), and secondary (symphysis) joints between hyaline-lined articular surfaces and an intervening ibrocartilaginous disc. Primary joints allow for growth and some bending, whereas secondary joints allow for strength and some lexibility. Synovial joints generally allow for considerable movement and are classiied according to their shape and the type of movement that they permit (uniaxial, biaxial, or multiaxial movement). Condyloid (ellipsoid; sometimes classiied separately): are biaxial joints for lexion, extension, abduction, adduction, and circumduction. Ball-and-socket (spheroid): are multiaxial joints for lexion, extension, abduction, adduction, mediolateral rotation, and circumduction. Skeletal muscle is divided into fascicles (bundles), which are composed of muscle ibers (muscle cells). Each myoibril is composed of many myoilaments, which are composed of individual myosin (thick ilaments) and actin (thin ilaments) that slide over one another during muscle contraction. Plane 12 Chapter 1 Introduction to the Human Body Clinical Focus 1-4 Fractures Fractures are classified as either closed (the skin is intact) or open (the skin is perforated; often referred to as a compound fracture). Additionally, the fracture may be classified with respect to its anatomical appearance. Closed fracture with hematoma Open fracture with bleeding Intraarticular fracture with hemarthrosis Pathologic fracture (tumor or bone disease) Greenstick fracture Torus (buckle) fracture In children Transverse fracture Oblique fracture Spiral fracture Comminuted fracture Segmental fracture Impacted fracture Avulsion (greater tuberosity of humerus avulsed by supraspinatus m. Osteoarthritis can affect any synovial joint but most often involves the foot, knee, hip, spine, and hand. As the articular cartilage is lost, the joint space (the space between the two articulating bones) becomes narrowed, and the exposed bony surfaces rub against each other, causing significant pain. Arteries carry blood away from the heart, and veins carry blood back to the heart. Arteries generally have more smooth muscle in their walls than veins and are responsible for most of the vascular resistance, especially the small muscular arteries and arterioles. Alternatively, at any point in time, most of the blood resides in the veins (about 64%) and is returned to the right side of the heart; thus veins are the capacitance vessels, capable of holding most of the blood, and are far more variable and numerous than their corresponding arteries. Fixator: one or more muscles that steady the proximal part of a limb when a more distal part is being moved. Synergist: a muscle that complements (works synergistically with) the contraction of the agonist, either by assisting with the movement generated by the agonist or by reducing unnecessary movements that would occur as the agonist contracts. Buffy coat <1% Blood clot formation and tissue repair Other solutes Electrolytes Normal extracellular fluid ion composition essential for vital cellular activities. Veins are capacitance vessels because they are distensible and numerous and can serve as reservoirs for the blood. Because veins carry blood at low pressure and often against gravity, larger veins of the limbs and lower neck region have numerous valves that aid in venous return to the heart (several other veins throughout the body may also contain valves). Both the presence of valves and the contractions of adjacent skeletal muscles help to "pump" the venous blood against gravity and toward the heart. In most of the body, the veins occur as a supericial set of veins in the subcutaneous tissue that connects with a deeper set of veins that parallel the arteries. Heart he heart is a hollow muscular (cardiac muscle) organ that is divided into four chambers. Chapter 1 Introduction to the Human Body 19 1 Clinical Focus 1-6 Atherogenesis Thickening and narrowing of the arterial wall and eventual deposition of lipid into the wall can lead to one form of atherosclerosis. The narrowed artery may not be able to meet the metabolic needs of the adjacent tissues, which may become ischemic. Multiple factors, including focal inflammation of the arterial wall, may result in this condition. When development of a plaque is such that it is likely to rupture and lead to thrombosis and arterial occlusion, the atherogenic process is termed unstable plaque formation. Fatty streak at margin Lumen Thrombus Plaque rupture Plaques likely to rupture are termed unstable. Total or partial occlusion of coronary artery can cause angina or frank myocardial infarction. Fibrinogen Fibrin Erythrocyte Platelet Fibrous cap Intimal disruption and thrombus pulmonary (pulmonic) valve and the aortic valve (both semilunar valves), respectively. Mitral valve Ascending aorta Aortic valve Introduction to the Human Body Right auricle Ascending aorta Aortic valve Outflow to pulmonary trunk Superior vena cava Right ventricle Moderator band Left ventricle Tricuspid valve Right posterior papillary m. Right ventricle Muscular part of interventricular septum Left anterior papillary m. Lymphatic vessels transport lymph from everywhere in the body major lymphatic channels. A much smaller right lymphatic duct drains the right upper quadrant of the body lymphatics to a similar site on the right side. Along the route of these lymphatic vessels, encapsulated lymph nodes are strategically placed to "ilter" the lymph as it moves toward the venous system. Immune Response When a foreign microorganism, virus-infected cell, or cancer cell is detected within the body, the lymphatic system mounts what is called an immune response. Neurons Nerve cells are called neurons, and their structure relects the functional characteristics of an individual neuron. Information comes to the neuron largely through treelike processes called axons, which terminate on the neuron at specialized junctions called synapses. Synapses can occur on neuronal processes called dendrites or on the neuronal cell body, called a soma or perikaryon. Neurons convey eferent (motor or output) information via action potentials that course along a single axon arising from the soma that then synapses on a selective target, usually another neuron or target cell, such as muscle cells. Chapter 1 Introduction to the Human Body 23 1 Clinical Focus 1-7 Asthma Asthma can be intrinsic (no clearly defined environmental trigger) or extrinsic (has a defined trigger). Asthma usually results from a hypersensitivity reaction to an allergen (dust, pollen, mold), which leads to irritation of the respiratory passages and smooth muscle contraction (narrowing of the passages), swelling (edema) of the epithelium, and increased production of mucus. Presenting symptoms are often wheezing, shortness of breath, coughing, tachycardia, and feelings of chest tightness. Asthma is a pathologic inflammation of the airways and occurs in both children and adults. Normal bronchus Mucosal surface Epithelium Basement membrane Opening of submucosal gland Blood vessel Smooth m. Cartilage Submucosal gland Increased mucus production Early asthmatic response Smooth m. Neurons may possess numerous branching dendrites, studded with dendritic spines that increase the receptive area of the neuron many-fold. Ependymal cells: these cells line the ventricles of the brain and the central canal of the spinal cord, which contains cerebrospinal luid. Peripheral nerves include the 12 pairs of cranial nerves arising from the brain or brainstem and the 31 pairs of spinal nerves arising from the spinal cord. Meninges he brain and spinal cord are surrounded by three membranous connective tissue layers called the meninges. V Trigeminal Sensory-face sinuses, teeth h Op M tha ill lm ic ax ary nd Ma ibu lar Motor-mm. Anterior ramus Gray ramus communicans Anterior root Sympathetic chain ganglion Free endings Splanchnic n. Sensory neuron of abdominal viscera Sensory Motor Preganglionic sympathetic White ramus communicans Sympathetic chain Preganglionic sympathetic neurons passing to synapse in another sympathetic chain ganglion Neuroeffector junctions on smooth m. Clinically, dermatome maps of the body can be helpful in localizing spinal cord or peripheral nerve lesions (see Chapter 2). Preganglionic axons exit the T1-L2 spinal cord in an anterior root, then enter a spinal nerve, and then via a white ramus communicans enter the sympathetic chain. Once in the sympathetic chain, the preganglionic axon may take one of three synaptic routes: 1. Synapse on a postganglionic sympathetic neuron at the T1-L2 level, or ascend or descend to synapse on a sympathetic chain neuron at any of the 31 spinal nerve levels. Pass through the sympathetic chain, enter a splanchnic (visceral) nerve, and synapse in a collateral ganglion in the abdominopelvic cavity. Pass through the sympathetic chain, enter a splanchnic nerve, pass through a collateral ganglion, and synapse on the cells of the adrenal medulla (the central portion of the adrenal gland). Reenter the spinal nerve via a gray ramus communicans and join any one of the 31 spinal nerves as they distribute widely throughout the body. Reenter the spinal nerve but course along blood vessels in the head, or join cardiopulmonary or hypogastric plexuses of nerves to distribute to the head, thorax, and pelvic viscera. Arise from postganglionic neurons in collateral ganglia and course with blood vessels to abdominopelvic viscera. Cells of the adrenal medulla are diferentiated neuroendocrine cells (paraneurons) that do not have axons but release hormones directly into the bloodstream. Exit the sacral spinal cord via an anterior root and then enter the pelvic splanchnic nerves, to synapse on postganglionic neurons in terminal ganglia located in or near the viscera to be innervated. Pass from the parasympathetic ganglion in the head on existing nerves or blood vessels, to innervate smooth muscle and glands of the head. Pass from terminal ganglia in or near the viscera innervated and synapse on smooth muscle, cardiac muscle, or glands in the neck, thorax, and abdominopelvic cavity. Speciically, the endocrine system interacts with target sites (cells and tissues), some that are quite a distance from a gland, by releasing hormones into the bloodstream. Again, the endocrine system is widespread and critically important in regulating bodily functions. Postganglionic fibers Enteric nervous system Myenteric Submucosal plexus plexus Smooth m. More than 20 diferent transmitter substances have been identiied in the intrinsic neurons of the enteric nervous system, pointing to the ine degree of regulation that occurs at the level of the bowel wall.

The spinous process of the L3 vertebra is slanted slightly posteroinferior to the more anterior L3 vertebral body anxiety symptoms or heart problems buy sinequan 25mg visa. Because of the lower extent of the rib cage anxiety 60mg cymbalta 90 mg prozac purchase sinequan 10mg fast delivery, the thorax also ofers protection for some of the abdominal viscera anxiety pathophysiology buy 10mg sinequan overnight delivery, including the liver and gallbladder on the right side anxiety questionnaire for adolescent 25 mg sinequan overnight delivery, the stomach and spleen on the left side anxiety breathing problems sinequan 75 mg on line, and the adrenal (suprarenal) glands and upper poles of the kidneys on both sides anxiety 10 things sinequan 25mg with amex. Clinicians often refer to "thoracic outlet syndrome," which describes symptoms associated with compression of the brachial plexus as it passes over the irst rib (speciically, the T1 anterior ramus). Additionally, the thorax contains two pleural cavities laterally and a central "middle space" called the mediastinum, which is divided as follows. Sternal head Clavicular head Clavicle Axilla Anterior axillary fold Posterior axillary fold Clavicular head Sternal head Pectoralis major m. Xiphoid process: marks the inferior extent of the sternum and the anterior attachment point of the diaphragm. Planes of Reference In addition to the sternal angle of Louis, physicians often use other imaginary planes of reference to assist in locating underlying visceral structures of clinical importance. Midvertebral line (also called the "posterior median" line): vertically bisects the vertebral column. However, ribs 1, 10, 11, and 12 usually articulate only with the vertebra of the same number. Rib fractures can be a relatively common and very painful injury (we must continue to breathe) but are less common in children because their thoracic wall is still fairly elastic. Joints of Thoracic Cage Joints of the thoracic cage include articulations between the ribs and the thoracic vertebrae (discussed in the preceding section), and between the ribs and the sternum. Muscles of Anterior Thoracic Wall he musculature of the anterior thoracic wall includes several muscles that attach to the thoracic cage but that actually are muscles that act on the upper limb. Note that the external intercostal muscles are replaced by the anterior intercostal membrane at the costochondral junction anteriorly, and that the internal intercostal muscles extend posteriorly to the angle of the ribs and then are replaced by the posterior intercostal membrane. These injuries can involve the heart, great vessels, tracheobronchial tree, and/or thoracic cage. Cage injuries often involve rib fractures (ribs 1 and 2 and 11 and 12 are more protected and often escape being fractured), crush injuries with rib fractures, and penetrating chest wounds such as gunshot and stab wounds. The pain caused by rib fractures can be intense because of the expansion and contraction of the rib cage during respiration; it sometimes requires palliation by anesthetizing the intercostal nerve (nerve block). Simple Complicated Costovertebral dislocation (any level) Transverse rib fracture Oblique rib fracture Overriding rib fracture Chondral fracture Costochondral separation Chondrosternal separation Sternal fracture Traumatization of pleura and of lung (pneumothorax, lung contusion, subcutaneous emphysema) Multiple rib fractures Tear of blood vessels (hemothorax) Compound by missile or by puncture wound Injury to heart or to great vessels Intercostal nerve block to relieve pain of fractured ribs 1 2 2 1 Needle introduced to contact lower border of rib (1), withdrawn slightly, directed caudad, advanced 1/8 inch to slip under rib and enter intercostal space (2). Parasternal 5 extend from the midclavicular line to about the angles of the ribs posteriorly. Intercostal Vessels and Nerves he intercostal neurovascular bundles (vein, artery, and nerve) lie inferior to each rib, running in the costal groove deep to the internal intercostal muscles. Posterior intercostal arteries arise from the aorta, except for the first two, which arise from the supreme intercostal artery, a branch of the costocervical trunk of the subclavian artery. First two posterior branches derived from superior intercostal branch of costocervical trunk and lower nine from thoracic aorta; these anastomose with anterior branches derived from internal thoracic artery (1st-6th spaces) or its musculophrenic branch (7th-9th spaces); the lowest two spaces only have posterior branches. Intercostals Subcostal Pericardiacophrenic Chapter 3 Thorax Arteries of the internal thoracic wall 99 3 Subclavian a. Veins of the thoracic wall Right brachiocephalic vein Left superior intercostal vein Left brachiocephalic vein Right superior intercostal vein Internal thoracic vein Posterior intercostal vein Azygos vein Hemiazygos vein Anterior intercostal vein Internal thoracic a. Distribution of intercostal nerves and arteries Spinal ganglion Posterior ramus of thoracic n. The posterior ramus of each nerve innervates the intrinsic muscles of the back and the overlying skin. Note the muscle layers and other features of the thoracic wall in this cross-sectional view. Female Breast he female breast, a modified sweat gland, extends from approximately the second rib to the sixth rib and from the sternum medially to the midaxillary line laterally. Mammary tissue is composed of compound tubuloacinar glands organized into Chapter 3 Thorax about 15 to 20 lobes, which are supported and separated from each other by fibrous connective tissue septae (the suspensory ligaments of Cooper) and fat. Fibroadenoma, the second most common form of breast disease and the most common breast mass, has a peak incidence in patients between 20 and 25 years of age, with most below the age of 30 years. The tumors are benign neoplasms of the glandular epithelium and usually are accompanied by a significant increase in periductal connective tissue. They usually present as firm, painless, mobile, solitary palpable masses that may grow rapidly during adolescence and warrant follow-up evaluation. Fibrocystic disease Sagittal section Schema of clinical syndrome: tender, granular swelling Fibroadenoma Tumor being excised from breast Benign intracystic papilloma Fibrous stalk Papilloma within breast tissue Discharge from nipple Chapter 3 Thorax 103 3 Clinical Focus 3-3 Breast Cancer Breast cancer is the most common malignancy in women, and women in the United States have the highest incidence in the world. The most common type (occurring in about 75% of cases) is an infiltrating ductal carcinoma, which may involve the suspensory ligaments, causing retraction of the ligaments and dimpling of the overlying skin. About 60% of the palpable tumors are located in the upper outer breast quadrant (the quadrant closest to the axilla, which includes the axillary tail). Distant sites of metastasis include the lungs and pleura, liver, bones, and brain. Nipple retraction Carcinomatous involvement of mammary ducts may cause duct shortening and retraction or inversion of nipple. Resultant edema creates "orange peel" appearance owing to prominence of skin gland orifices. Carcinoma Pectoralis fascia 104 Chapter 3 Thorax Clinical Focus 3-4 Partial Mastectomy Several clinical options are available to treat breast cancer, including systemic approaches (chemotherapy, hormonal therapy, immunotherapy) and "local" approaches (radiation therapy, surgery). In a partial mastectomy, also called "lumpectomy" or "quadrantectomy," the surgeon performs a breast-conserving surgery that removes the portion of the breast that harbors the tumor along with a surrounding halo of normal breast tissue. Because of the possibility of lymphatic spread, especially to the axillary nodes, an incision also may be made for a sentinel node biopsy to examine the first axillary node, which is likely to be invaded by metastatic cancer cells from the breast. Breast nodes and carcinoma Central axillary nodes Posterior axillary (subscapular) nodes Lateral axillary (humeral) nodes Apical axillary (subclavian) nodes Internal jugular vein B. Dissection of breast Axillary vein and lymph nodes Stellate, irregular mass Pectoral fascia D. Care is taken to preserve the pectoralis, serratus anterior, and latissimus dorsi muscles and the long thoracic and thoracodorsal nerves to the latter two muscles, respectively. Damage to the long thoracic nerve results in "winging" of the scapula, and damage to the thoracodorsal nerve weakens extension at the shoulder. A B During development of the skin flaps, the breast tissue is retracted downward while the flaps, superior and inferior, are retracted perpendicularly to the chest wall. Normally, the pleural cavity contains a small amount of serous luid, which lubricates the surfaces and reduces friction during respiration. Over most of the surface of the diaphragm and in the parietal pleura facing the mediastinum, the aferent pain ibers course in the phrenic nerve (C3-C5). Clinically, it is important for physicians to be able to "visualize" the extent of the lungs and pleural cavities topographically on the surface of their patients. In quiet respiration, the lung margins reside two ribs above the extent of the pleural cavity at the midclavicular, midaxillary, and paravertebral lines (Table 3. The Lungs he paired lungs are invested in the visceral pleura and are attached to mediastinal structures (trachea and heart) at their hilum. Both lungs are composed of spongy and elastic tissue, which readily expands and contracts to conform to the internal contours of the thoracic cage. Usually, one small right bronchial artery and a pair of left bronchial arteries (superior and inferior) can be found on the posterior aspect of the main bronchi. Although much of this blood returns to the heart via the pulmonary veins, some also collects into small bronchial veins that drain into the azygos system of veins. Lymph then drains into tracheobronchial nodes at the tracheal bifurcation and into right and left paratracheal nodes. Clinicians often use diferent names to identify these nodes (intrapulmonary, hilar, carinal, and scalene), so these clinical terms are listed in parentheses after the corresponding anatomical labels in. Sympathetic bronchodilator ibers relax smooth muscle, vasoconstrict pulmonary vessels, and inhibit the bronchial tree alveolar glands. Parasympathetic bronchoconstrictor ibers contract bronchial smooth muscle, vasodilate pulmonary vessels, and initiate secretion of alveolar glands. Pain (nociceptive) aferents from the visceral pleura and bronchi pass back via the sympathetic ibers, through the sympathetic trunk, and to the sensory spinal ganglia of the upper thoracic spinal cord levels. Respiration During quiet inspiration the contraction of the respiratory diaphragm alone accounts for most of the decrease in intrapleural pressure, allowing air to expand the lungs. Active inspiration occurs when 108 Right lung Apex Chapter 3 Thorax Groove for superior vena cava Groove for azygos v. Oblique fissure Pleura (cut edge) Superior lobe Right superior lobar (eparterial) bronchus Right pulmonary a. Bronchopulmonary (hilar) lymph nodes Horizontal fissure Cardiac impression Middle lobe Oblique fissure Diaphragmatic surface Apex Right inferior pulmonary vv. Left lung Area for trachea and esophagus Oblique fissure Groove for arch of aorta Pleura (cut edge) Left pulmonary a. Groove for descending aorta Diaphragmatic surface Cardiac impression Pulmonary lig. Use ultrasonography to locate the 4th and 5th intercostal spaces in the anterior axillary line at the level of the nipple. Administer anesthetic to a 2- to 3-cm area of the skin and subcutaneous tissue at incision site (A). Continue to anesthetize deeper subcutaneous A tissues and intercostal B muscles (B). Identify the rib inferior to the intercostal space where tube will be inserted and anesthetize the periosteal surface (C). Advance the needle until a flash of pleural fluid or air enters the syringe, confirming entry into the pleural space. Open the clamp while inside the pleural space and then withdraw so that all layers of the dissected tract are enlarged. Insert a finger into the pleural space and rotate 360 degress to feel for adhesions. Use a Kelly clamp to grab fenestrated portion of the tube and introduce it through the insertion site. Right paratracheal nodes Chapter 3 Thorax Left paratracheal nodes Bronchomediastinal lymphatic trunk Right lymphatic duct Subclavian v. Interlobular lymph vessels Inferior tracheobronchial (carinal) nodes Drainage routes Right lung: All lobes drain to pulmonary and bronchopulmonary (hilar) nodes, and then to inferior tracheobronchial (carinal) nodes. Left lung: Superior lobe drains to pulmonary and bronchopulmonary (hilar) nodes and inferior tracheobronchial (carinal) nodes. Left inferior lobe drains also to pulmonary and bronchopulmonary (hilar) nodes and to inferior tracheobronchial (carinal) nodes, but then mostly to right superior tracheobronchial nodes, where it follows same route as lymph from right lung. Although the first rib is stationary, ribs 2 to 6 tend to increase the anteroposterior diameter of the chest wall, and the lower ribs mainly increase the transverse diameter. Accessory muscles of inspiration that attach to the thoracic cage may also assist in very deep inspiration. During quiet expiration the elastic recoil of the lungs, relaxation of the diaphragm, and relaxation of the thoracic cage muscles expel the air. In forced expiration the abdominal muscles contract and, by compressing the abdominal viscera superiorly, raise the intraabdominal pressure and force the diaphragm upward. Trachea and Bronchi he trachea is a single midline airway that extends from the cricoid cartilage to its bifurcation at the sternal angle of Louis. It lies anterior to the esophagus and is rigidly supported by 16 to 20 C-shaped cartilaginous rings. Each lobar bronchus then divides again into tertiary bronchi supplying the 10 bronchopulmonary segments of each lung (some clinicians identify 8 to 10 segments in the left lung, whereas anatomists identify 10 in each lung). Chronic restrictive lung diseases account for approximately 15% of noninfectious lung diseases and include a diverse group of disorders with reduced compliance that cause chronic inflammation, fibrosis, and the need for more pressure to inflate the stiffened lungs. Dyspnea Cyanosis Nonproductive hacking cough Diffuse pulmonary fibrosis on x-ray film Clubbing of fingers Basilar inspiratory ("Velcro") crackles Loss of weight Elevated diaphragm Cor pulmonale (late) Diffuse bilateral fibrosis of lungs with multiple small cysts giving honeycomb appearance 112 Chapter 3 Thorax Clinical Focus 3-8 Pulmonary Embolism the lungs naturally filter venous clots larger than circulating blood cells and can usually accommodate small clots because of their fibrinolytic ("clot buster") mechanisms. Saddle embolus, on the other hand, is an emergency that can precipitate acute cor pulmonale (right-sided heart failure) and circulatory collapse. Sources of pulmonary emboli Most Common Sources of Pulmonary Emboli Less Common Sources of Pulmonary Emboli Massive embolization Right side of heart Gonadal (ovarian or testicular) v. Lung cancer arises either from alveolar lining cells of the lung parenchyma or from the epithelium of the tracheobronchial tree. Although there are a number of types, squamous cell (bronchiogenic) carcinoma (about 20% of lung cancers in the United States) and adenocarcinoma (from intrapulmonary bronchi; about 37% of lung cancers in the United States) are the most common types. For example, in Pancoast syndrome, this apical lung tumor may spread to involve the sympathetic trunk, affect the lower portion of the brachial plexus (C8, T1, and T2), and compromise the sympathetic tone to the head. Emphysema is characterized by permanent enlargement of air spaces at and distal to the respiratory bronchioles, with destruction of the bronchiole walls by chronic inflammation. As a result, lung compliance increases because the elastic recoil of the lung decreases, causing collapse of the airways during expiration. This increases the work of expiration as patients try to force air from their diseased lungs and can lead to a "barrel-chested" appearance caused by hypertrophy of the intercostal muscles. She may have chronic cough and sputum production, and need accessory muscles and pursed lips to help her breathe. Radiographic imaging often shows components of airway wall thickening, excessive mucus, and emphysema.

However anxiety 36 weeks pregnant purchase sinequan 10mg free shipping, it is not known what initiates the inflammatory response in the gallbladder wall anxiety symptoms in your head proven 25mg sinequan. In some patients anxiety medication for teens cheap sinequan 75mg online, repeated attacks of mild acute cholecystitis result in chronic cholecystitis anxiety symptoms 10 year old 25mg sinequan overnight delivery. The wall of the gallbladder is thickened which on cut section is grey-white due to dense fibrosis or may be even calcified anxiety obsessive thoughts order 75 mg sinequan amex. Variable degree of chronic inflammatory reaction anxiety in toddlers purchase 10mg sinequan with amex, consisting of lymphocytes, plasma cells and macrophages, present in the lamina propria and subserosal layer. A few morphologic variants of chronic cholecystitis are: Cholecystitis glandularis Porcelain gallbladder Acute on chronic cholecystitis. Generally, the patient-a fat, fertile, female of forty or fifty, presents with abdominal distension or epigastric discomfort, especially after a fatty meal. There is a constant dull ache in the right hypochondrium and epigastrium and tenderness over the right upper abdomen. Cholelithiasis and cholecystitis the most significant association of cancer of the gallbladder is with cholelithiasis and cholecystitis, though there is no definite evidence of causal relationship. Chemical carcinogens these include methyl cholanthrene, various nitrosamines and pesticides. Genetic factors There is higher incidence of cancer of the gallbladder in certain populations living in the same geographic region suggesting a strong genetic component in the disease. Miscellaneous Patients who have undergone previous surgery on the biliary tract have higher incidence of subsequent gallbladder cancer. Infiltrating type appears as an irregular area of diffuse thickening and induration of the gallbladder wall. Fungating type grows like an irregular, friable, papillary or cauliflower-like growth into the lumen as well as into the wall of the gallbladder and beyond. They may be papillary or infiltrative, well-differentiated or poorly-differentiated. About 5% of gallbladder cancers are squamous cell carcinomas arising from squamous metaplastic epithelium. A few cases show both squamous and adenocarcinoma pattern of growth called adenosquamous carcinoma. Quite often, the diagnosis is made when gallbladder is removed for cholelithiasis. The symptomatic cases have pain, jaundice, noticeable mass, anorexia and weight loss. However, when the tumour is advanced, it is indistinguishable from 3 other cancers in the vicinity: i) cancer of adjacent duodenal mucosa with secondary involvement of ampulla; ii) cancer of terminal third of bile duct infiltrating in the ampulla; and iii) carcinoma of the head of pancreas merging into the ampulla. Therefore, in adavanced cancer involving the ampulla, the term periampullary carcinoma is used that encompasses cancer from all 4 anatomic sites: i) ampulla of Vater, ii) duodenum, iii) terminal part of common bile duct, and iv) the head of pancreas. Bile duct cancers are associated with a number of other conditions such as ulcerative colitis, sclerosing cholangitis, parasitic infestations of the bile ducts with Fasciola hepatica (liver fluke), Ascaris lumbricoides and Clonorchis sinensis. M/E the tumour is usually adenocarcinoma varying from well-differentiated to poorly differentiated and may or may not be mucin-secreting. Prognosis of ampullary carcinoma is better than than pancreatic cancer and bile duct carcinoma. The exocrine part is divided into rhomboid lobules separated by thin fibrous tissue septa containing blood vessels, lymphatics, nerves and ducts. The disease has an autosomal recessive inheritance but clinical features are apparent in homozygotes only with apparent clinical features in homozygotes only. The clinical manifestations may appear at birth or later in adolescence and pertain to multiple organs and systems such as pancreatic insufficiency, intestinal obstruction, steatorrhoea, malnutrition, hepatic cirrhosis and respiratory complications. The acini are atrophic and many of the acinar ducts contain laminated, eosinophilic concretions. Liver the bile canaliculi are plugged by viscid mucous which may cause diffuse fatty change, portal fibrosis and ductular proliferation. Respiratory tract Changes in the respiratory passages are seen in almost all typical cases of cystic fibrosis. The viscid mucous secretions of the submucosal glands of the respiratory tract cause obstruction, dilatation and infection of the airways. Salivary glands Pathologic changes in the salivary glands are similar to those in pancreas and include obstruction of the ducts, dilatation, fibrosis and glandular atrophy. Sweat glands Hypersecretion of sodium and chloride in the sweat observed in these patients may be reflected pathologically by diminished vacuolation of the cells of eccrine glands. The severe form of the disease associated with macroscopic haemorrhages and fat necrosis in and around the pancreas is termed acute haemorrhagic pancreatitis or acute pancreatic necrosis. The condition occurs in adults between the age of 40 and 70 years and is commoner in females than in males. The onset of acute pancreatitis is sudden, occurring after a bout of alcohol or a heavy meal. The patient presents with abdominal pain, vomiting and collapse and the condition must be differentiated from other diseases producing acute abdomen. Characteristically, there is elevation of serum amylase level within the first 24 hours and elevated serum lipase level after 3 to 4 days, the latter being more specific for pancreatic disease. Less common causes of acute pancreatitis include trauma, ischaemia, shock, extension of inflammation from the adjacent tissues, blood-borne bacterial infection, viral infections, certain drugs. Though more than 20 enzymes are secreted by exocrine pancreas, 3 main groups of enzymes which bring about destructive effects on the pancreas are: 1. The activation and release of these enzymes is brought about by one of the following mechanisms: i) Acinic cell damage ii) Duct obstruction iii) Block in exocytosis. Subsequently, in a day or two, characteristic variegated appearance of greywhite pancreatic necrosis, chalky-white fat necrosis and blue-black haemorrhages are seen. Inflammatory reaction, chiefly by polymorphs, around the areas of necrosis and haemorrhages. Most patients present with recurrent attacks of severe abdominal pain at intervals of months to years. Thus, most commonly, chronic pancreatitis is related to chronic alcoholism with protein-rich diet, and less often to biliary tract disease. Pathogenesis of alcoholic and non-alcoholic chronic pancreatitis is explained by different mechanisms: 1. Chronic pancreatitis due to chronic alcoholism accompanied by a highprotein diet results in increase in protein concentration in the pancreatic juice which obstructs the ducts and causes damage. Non-alcoholic cases of chronic pancreatitis seen in tropical countries (tropical chronic pancreatitis) result from protein-calorie malnutrition. Foci of calcification and tiny pancreatic concretions to larger visible stones are frequently found. The patients generally present with abdominal mass producing pain, intraperitoneal haemorrhage and generalised peritonitis. Usually it is solitary, unilocular, measuring up to 10 cm in diameter with thin or thick wall. M/E the cyst wall is composed of dense fibrous tissue with marked inflammatory reaction. There is evidence of preceding haemorrhage and necrosis in the form of deposits of haemosiderin pigment, calcium and cholesterol crystals. It is commoner in males than in females and the incidence increases progressively after the age of 50 years. Diet and obesity: Diet with high total caloric value and high consumption of animal proteins and fats is related to higher incidence of pancreatic cancer. Chemical carcinogens: Individuals exposed to b-naphthylamine, benzidine and nitrosamines have higher incidence of cancer of the pancreas. Diabetes mellitus: Patients of long-standing diabetes mellitus have a higher incidence. G/A Carcinoma of the head of pancreas is generally small, homogeneous, poorly-defined, grey-white mass without any sharp demarcation between the tumour and the surrounding pancreatic parenchyma. The tumour of the head extends into the ampulla of Vater, common bile duct and duodenum, producing obstructive biliary symptoms and jaundice early in the course of illness. Well-differentiated adenocarcinoma, both mucinous and non-mucin secreting type, is the most common pattern. Adenoacanthoma consisting of glandular carcinoma and benign squamous elements is seen in a proportion of cases. Rarely, peculiar tumour giant cell formation is seen with marked anaplasia, pleomorphism and numerous mitoses. Acinar cell carcinoma occurs rarely and reproduces the pattern of acini in normal pancreas. Obstructive jaundice More often and early in the course of disease in cases with carcinoma head of the pancreas (80%). Carbon tetrachloride the form of bilirubin which remains detectable in serum for sufficient time after recovery from the disease is: A. Delta bilirubin Acute viral hepatitis by the following hepatotropic virus is characterised by fatty change in liver: A. Hypoprothrombinaemia showing improvement following parenteral administration of vitamin K 421 Chapter 19 the Liver, Biliary Tract and Exocrine Pancreas 4. Elevated serum bile acids the following conditions have unconjugated hyperbiliru binaemia except: A. Gilbert syndrome Kernicterus often develops in the following type of hereditary hyperbilirubinaemia: A. There is decreased activity of mitochondrial enzymes in the liver Hepatic encephalopathy is due to: A. Hepatopulmonary syndrome Following etiologic factors are implicated in BuddChiari syndrome except: A. Pregnancy Councilman bodies in viral hepatitis are a form of apoptosis seen commonly at the following site: A. Vast majority (more than 90%) of cases of posttransfusion hepatitis are caused by: A. Primary biliary cirrhosis Primary biliary cirrhosis has the following features except: A. The disease has autoimmune origin Patients of following type of cirrhosis more often may develop hepatocellular carcinoma as a late complication: A. Serum copper low-to-normal-to-high Intrahepatic causes of portal hypertension include the following except: A. Metastatic tumours In developed countries the major risk factor in the pathogenesis of hepatocellular carcinoma is: A. Aflatoxin B1 423 Chapter 19 the Liver, Biliary Tract and Exocrine Pancreas 424 Risk factors implicated in the etiology of cholesterol gallstones include the following except: A. The following type of gallstones are generally unassociated with changes in the gallbladder wall: A. Pancreatic carcinoma of the following site more often produces obstructive jaundice: A. A 40 years old woman presents with fever, malaise, signs of jaundice, claycoloured stools, and highcoloured urine for 10 days. A liver biopsy reveals hepatocyte drop out necrosis, focal inflammation and ballooning degeneration and a few intensely eosinophilic oval bodies are found. Which of the following abnormalities is most likely to be observed in a known case of hereditary haemochromatosis The hilum of the kidney is situated at the midpoint on the medial aspect where the artery, vein, lymphatics and ureter are located. The kidney is surrounded by a thin fibrous capsule which is adherent at the hilum. Cut surface of the kidney shows 3 main structures: well-demarcated peripheral cortex, inner medulla and the innermost renal pelvis: the renal cortex forms the outer rim of the kidney and is about 1 cm in thickness. The base of a renal pyramid lies adjacent to the outer cortex and forms the cortico-medullary junction, while the apex of each called the renal papilla contains the opening of each renal pyramid for passage of urine. The renal pelvis is the funnel-shaped collection area of the urine for drainage into the ureter. The minor calyces (8-18 in number in a normal kidney) collect urine from renal papillae and drain into major calyces (2-3 in a normal kidney). From point of view of diseases of the kidneys, 4 components of renal parenchyma require further elaboration: renal vasculature, glomeruli, tubules and interstitium. Renal vasculature Each kidney is supplied with blood by a main renal artery which arises from the aorta at the level of the 2nd lumbar vertebra. It is from the interlobular arteries that the afferent arterioles take their origin, each one supplying a single glomerulus. The following important inferences can be drawn from the peculiarities of the renal vasculature: i) the renal cortex receives about 90% of the total renal blood supply and that the pressure in the glomerular capillaries is high. Thus, occlusion of any of the branches results in infarction of the renal parenchyma supplied by it. Glomerulus the glomerulus consists of invagination of the blind end of the proximal tubule and contains a capillary tuft fed by the afferent arteriole and drained by efferent arteriole. The capillary tuft is covered by visceral epithelial cells (podocytes) which are continuous with those of the parietal epithelium at the vascular pole. The transition to proximal tubular cells occurs 426 at the urinary pole of the glomerulus. Subdivisions of capillaries derived from the afferent arterioles result in the formation of lobules (up to 8 in number) within a glomerulus. Each lobule of a glomerular tuft consists of a centrilobular supporting stalk composed of mesangium containing mesangial cells (3 per lobule) and mesangial matrix. The major function of glomerulus is complex filtration from the capillaries to the urinary space. The barrier to glomerular filtration consists of the following 3 components: i) Fenestrated endothelial cells lining the capillary loops.

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Indications In the healthy individual anxiety 60mg cymbalta 90 mg prozac generic 25mg sinequan, normal sensations of thirst promote the consumption of adequate fluid and the maintenance of optimum hydration (1) anxiety symptoms head pressure cheap sinequan 25mg visa. However anxiety treatment for children generic 25mg sinequan with mastercard, some patients may not recognize thirst anxiety symptoms in adults sinequan 25mg for sale, may not be able to communicate thirst anxiety tumblr buy sinequan 75mg visa, or may not freely consume liquids anxiety level test buy sinequan 25mg mastercard. Risk factors for dehydration include any of the following: unconscious; semiconscious and confused state severe depression tranquilizer or sedative use enteral feeding must be fed or require assistance with feeding diarrhea poor appetite immobility diuretic use frequent laxative use perspiration (in hot weather where air conditioning is unavailable) dysphagia/swallowing difficulties increased respiratory rate salivation decreased by medications or radiation therapy fever fistulous drainage high output ileostomy vomiting severe burns polyuria. Evidence indicates that consuming up to six mg of caffeine per kilogram of body weight per day does not impact the hydration status of healthy adults, above that of a placebo or non-caffeine-containing beverage (Grade 1)*(2). Order should include amount of fluid to be given by Food and Nutrition Services with meals and snacks and amount of fluid to be given by nursing. Planning the Diet When the dietitian calculates the intake of fluids, foods that are liquid at room temperature should be counted by millileters. Such foods include water, carbonated beverages, coffee and tea, gelatin, milk, water ices and popsicles, soups, supplements, eggnog, ice cream and sherbet, and milk shakes. Nutrition Management of Fluid Intake and Hydration Fluid is usually ordered in the form of cubic centimeters (ml) (1 mL = 1 cc). Treatment is accomplished by increasing oral intake of fluid and electrolytes as needed. Patients with more severe cases and those who are unable to take fluids by mouth are treated by appropriate intravenous fluid replacement. Replacement water requirements may be greatly increased in peritonitis, pancreatitis, enteritis, ileus, or portal vein thrombosis. In some cases, a precise intake and output record may be necessary to determine and meet fluid requirements. Currently, no evidence exists comparing which methods are best to use when estimating fluid needs in adults (Grade V) (2). These along with other methods are described below: Guidelines for calculating fluid needs based on age (applies to critical care patients): 1. Patients treated on air-fluidized beds set at higher temperatures are at greater risk of dehydration due to an increase in insensible water loss associated with the warmer bed temperatures. Patients who require air-fluidized beds set at a higher temperature will need additional fluids, estimated to be approximately 10 to 15 mL/kg (7,8). Serial assessment of body weight is probably the most reliable parameter, especially because water makes up such a large proportion of total body weight (2). Along with serial assessment, the following physical alterations can be assessed to help determine hydration status (9). Volume deficit Decreased moisture in the oral cavity Decreased skin and tongue turgor (elasticity); skin may remain slightly elevated after being pinched Flattened neck and peripheral veins in supine position Decreased urinary output (<30 ml/h without renal failure) Acute weight loss (>1 lb /day) Volume excess Clinical apparent edema is usually not present until 12 15 L of fluid has accumulated 1 L fluid = 1 kg weight Pitting edema, especially in dependent parts of the body. Fluid loss causes hemoconcentration and serum osmolality; fluid gain causes hemodilution and decreases serum osmolality. Aging increases the risk for dehydration based on the physical and psychological changes. Nutrition Management of Fluid Intake and Hydration lack the ability to recognize thirst, have aged kidneys that may have a decreased ability to concentrate urine, fear urinary incontinence and thus do not drink sufficient fluids, have acute or chronic illnesses that alter fluid and electrolyte balance (10). Fluid Restriction In heart failure, ascites, end-stage renal disease, and other disorders, patients retain fluid. Position of the Academy of Nutrition and Dietetics: Food and nutrition for older adults: promoting health and wellness. A vegetarian whose diet consists of foods of plant origin only is a total vegetarian or vegan. However, many vegetarians also consume eggs (ovovegetarian), dairy products (lactovegetarian), or both eggs and dairy products (lacto-ovovegetarian). According to the Academy of Nutrition and Dietetics Evidence Analysis Library, these broad categories mask important variations within vegetarian diets. Indications Vegetarian diets are adopted for a variety of health, ecological, economical, philosophical, and ethical reasons (1). Vegetarian diets offer a number of health advantages, including lower blood cholesterol levels, lower blood pressure levels, and lower risks of hypertension, heart disease, and type 2 diabetes (1). Vegetarians tend to have a lower body mass index and lower overall cancer rates (1). Vegetarian diets tend to be lower in saturated fat and cholesterol and have higher levels of dietary fiber, magnesium, potassium, folate, antioxidants (eg, vitamins C and E), carotenoids, flavonoids, and other phytochemicals (1). These nutritional differences may explain some of the health advantages of a varied, balanced vegetarian diet (1). Many epidemiologic studies suggest a positive relationship between vegetarian lifestyles and reduced risks of several chronic degenerative diseases, such as ischemic heart disease (Grade I)* (1), coronary artery disease, hypertension, type 2 diabetes, obesity, renal disease, and some cancers (1). Nutritional Adequacy Vegan, lactovegetarian, ovovegetarian and lacto-ovovegetarian diets are healthful and nutritionally adequate when appropriately planned for all stages of the life cycle, including pregnancy and lactation (1). Appropriately planned vegan, lactovegetarian, ovovegetarian and lacto-ovovegetarian diets will meet the nutrient needs of infants, children, and adolescents to support and promote normal growth and development (1-3). Vegans and some other vegetarians may have lower intakes of vitamins B 12 and D, calcium, zinc, long-chain n-3 fatty acids, and occasionally iron (1). The greater production and access to fortified and enriched foods is making it easier for vegetarians to improve their intake of these key nutrients. If sun exposure is limited, vitamin D supplements or fortified foods should be emphasized (1-6). Results of evidence-based analysis suggest that vegetarian diets can be nutritionally adequate in pregnancy and can lead to a positive birth outcome (7). The nutrient and energy needs of pregnant and lactating vegetarian women do not differ from those needs of nonvegetarian women with the exception of higher iron recommendations for vegetarians (1). In addition to iron, key nutrients to assess in pregnancy include vitamin B12, vitamin D, and folate, whereas key nutrients in lactation include vitamin B 12, vitamin D, calcium, and zinc (1). Breast-fed infants whose mothers do not have an adequate intake of vitamin B 12 should receive a vitamin B12 supplement (1,4). In addition, the zinc intake of breast-fed infants should be carefully assessed; zinc supplements or zinc-fortified foods should be used when complementary foods are introduced if the diet is low in zinc or mainly consists of foods with low zinc bioavailability (1). Because of the variability of dietary practices among vegetarians, the individual assessment of dietary intakes is necessary (1). Planning the Diet A vegetarian diet can be made nutritionally adequate by careful planning and giving consideration to the following guidelines (1): Choose a variety of foods, including fruits, vegetables, whole grains, legumes, nuts, seeds, tofu or other soy products, and, if desired, dairy products and eggs. Choose whole or unrefined grain products whenever possible, instead of refined products. Manual of Clinical Nutrition Management Vegetarian Diet Minimize intake of foods that are highly sweetened, high in sodium, or high in fat, especially saturated fat and trans fatty acids. If animal foods such as dairy products and eggs are used, choose lower-fat dairy products and use both eggs and dairy products in moderation. Use a regular source of vitamin B12, and, if sunlight exposure is limited, provide a source of vitamin D. Although plant foods contain less of the essential amino acids than do equivalent quantities of animal foods, a plant-based diet can provide adequate amounts of amino acids when energy needs are met and a varied diet is consumed on a daily basis (1). Research indicates that an assortment of plant foods eaten over the course of a day can provide all essential amino acids and ensure adequate nitrogen retention and use in healthy adults; thus, complementary proteins do not need to be consumed at the same meal (1,8). A mixture of different proteins from unrefined grains, legumes, seeds, nuts, and vegetables will complement each other in their amino acid profiles to meet nutritional needs. Estimates of protein requirements may vary based on dietary choices selected, particularly for vegans. Isolated soy protein can meet protein needs as effectively as animal protein, whereas wheat protein eaten alone may be 50% less usable than animal protein (1). Therefore, protein needs might be somewhat higher than the Recommended Daily Allowance in those vegetarians whose dietary protein sources are mainly those that are less well digested, such as some cereals and legumes (1,9). The consumption of lysine, an essential amino acid, should be evaluated in persons who consume a vegan diet or who acquire a large percentage of protein from cereal sources. Dietary adjustments, such as the use of more beans and soy products in place of other protein sources that are lower in lysine or an increase in protein from all sources, can ensure an adequate intake of lysine (1,10). Vitamin B12: Unfortified plant foods do not contain significant amounts of active vitamin B 12. Although the requirement for vitamin B12 is relatively small, vegetarians must include a reliable source of vitamin B12 in their diets to reduce their risk of developing a deficiency. Lacto-ovovegetarians can obtain adequate vitamin B 12 from the regular consumption of dairy foods, eggs, fortified foods, or supplements (1). Vegans should supplement their diets with vitamin B12 by selecting fortified foods, such as fortified soy or rice beverages, breakfast cereals, meat analogs, or Red Star Vegetarian Support Formula nutritional yeast; otherwise, a daily vitamin B 12 supplement is needed to ensure an adequate intake of the active form of the nutrient (1). Older adults who are vegetarian should consume fortified foods or supplements to increase their vitamin B 12 intake, because the absorption of vitamin B12 often becomes less efficient in older adults due to atrophic gastritis (1). If vitamin B12 foods are not consumed regularly (at least three servings per day), patients are advised to take a daily vitamin B12 supplement of 5 to 10 mcg or a weekly B12 supplement of 2,000 mcg (11). Folacin-rich vegetarian diets may mask the hematological symptoms of vitamin B12 deficiency; therefore, a deficiency may go undetected until the manifestation of neurological signs and symptoms (1,13). The calcium intake of lactovegetarians is comparable to or higher than that of nonvegetarians (1). However, the calcium intake of vegans is generally lower than that of lactovegetarians and nonvegetarians and is often below the recommended level (1). In one study, the risk of bone fracture was similar for lacto-ovovegetarians and meat eaters, whereas vegans had a 30% higher risk of fracture possibly due to their considerably lower mean calcium intake (1,14). A diet that provides foods with relatively high ratios of sulfur-containing amino acid proteins, such as eggs, meat, fish, poultry, dairy products, nuts, and many grains, may increase calcium loss from the bones (1). Studies show that the ratio of dietary calcium to protein is more predictive of bone health than calcium intake alone (1). Typically, this ratio is high in lacto-ovovegetarian diets and favors bone health. However, vegan diets have calcium-to-protein ratios that are similar to or lower than those of nonvegetarian diets (1,15). Oxalates in some foods, such as spinach and Swiss chard, greatly reduce calcium absorption, making these vegetables a poorer source of usable calcium (1). If vegans do not meet calcium requirements from food, fortified foods and dietary supplements are recommended (1). If sun exposure and intake of fortified foods are insufficient to meet nutritional needs, vitamin D supplements are recommended (1). Vitamin D2 (ergocalciferol) is produced from ergosterol from yeast and is a form that may be more frequently used by vegans. There is disparity in the research as to whether the bioavailability of vitamin D 2 is less than that of vitamin D3 (1,16). The need for additional requirements when vitamin D2 sources are primarily used is not currently suggested by the evidence (1,16). Because cutaneous vitamin D production decreases with aging process, dietary or supplemental sources of vitamin D are important when assessing the diets of older adults (1,17). Energy: Because vegan diets tend to be high in bulk, it can be challenging for vegans, especially infants, children, and adolescents, to meet their energy needs. Frequent meals and snacks and the use of some refined foods (such as fortified breakfast cereals, breads, and pasta) and foods higher in unsaturated fats can help vegan children meet their energy and nutrient needs (1). Iron: the non-heme iron found in plant foods is more sensitive than heme iron to both inhibitors and enhancers of iron absorption (1). The inhibitors of iron absorption include phytate, calcium, and polyphenols in teas (including some herb teas), coffee, and cocoa (1). Some food preparation techniques, such as soaking and sprouting beans, grains, and seeds and the leavening of bread, can diminish phytate levels and thereby enhance iron absorption (1). Western vegetarians have a relatively high intake of iron from plant foods, such as dark-green leafy vegetables, iron-fortified cereals, and whole grains. Although vegetarian diets are higher in total iron than nonvegetarian diets, iron stores are lower because iron from plant foods is not absorbed as well as iron from animal sources (1). Because of the lower bioavailability of iron from a vegetarian diet, the recommended iron intakes for vegetarians are 1. However, the frequency of anemia is not higher in the vegetarian population than in the nonvegetarian population (1). There is evidence of long-term adaptation to low iron intakes that involves both increased absorption and decreased losses (1,20,21). In addition, vitamin C and other organic acids in fruits and vegetables consumed by vegetarians can substantially enhance iron absorption and reduce the inhibitory effects of phytates, leading to improved iron status (1). Zinc: Because phytate binds zinc, and animal protein is believed to enhance zinc absorption, total zinc bioavailability appears to be lower in vegetarian diets (1,22). In addition, breast-fed infants should have their diets evaluated for zinc intake. Zinc-fortified foods or supplements should be used when complementary foods are introduced, if the diet is low in zinc or mainly consists of foods with low zinc availability (1). Due to difficulty in evaluating zinc deficiency, it is not possible to determine the possible effect of lower zinc absorption from vegetarian diets (22). Food preparation techniques, such as the soaking and sprouting of beans, grains, and seeds, as well as the leavening of bread, can reduce the binding of zinc by phytic acid and increase zinc bioavailability (1,23). Organic acids, such as citric acid, can also enhance zinc absorption to some extent (1,23). Position of the American Dietetic Association and Dietitians of Canada: vegetarian diets. Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board, Institute of Medicine, National Academy of Sciences.