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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Dimitri T. Azar, MD, B.A.
https://chicago.medicine.uic.edu/departments/academic-departments/ophthalmology-visual-sciences/our-department/faculty/name/dimitri-azar/
Taking rectal temperatures is common practice in unresponsive patients at risk for biting down on the thermometer virus yardville cipro 750mg generic. It involves sensory antibiotic resistance database order cipro 500 mg mastercard, emotional treatment for distemper dogs order cipro 250mg on-line, and cognitive processing but may lack a specific physical etiology antibiotic resistance solutions buy 1000mg cipro visa. Chronic pain is defined in several ways: pain not associated with cancer or other medical conditions that persists for more than 3 to 6 months; pain lasting more than 1 month beyond the course of an acute illness or injury; or pain recurring at intervals of months or years. Accept the self-report, which experts state is the most reliable indicator of pain. Three scales are common: the Visual Analog Scale, and two scales using ratings from 1 to 10-the Numeric Rating Scale and the Faces Pain Scale. Attempted Treatments, Medications, Related Illnesses, and Impact on Daily Activities. Be sure to ask about any treatments that the patient has tried, including medications, physical therapy, and alternative medicines. A comprehensive medication history helps you to identify drugs that interact with analgesics and reduce their efficacy. Clinician stereotypes, language barriers, and unconscious clinician biases in decision making all contribute to these disparities. Critique your own communication style, seek information and best practice standards, and improve your techniques of patient education and empowerment. Monitor the effectiveness of pain interventions, especially narcotics, by assessing the "four As": Analgesia, Activities of daily living, Adverse effects, and Aberrant drug-related behaviors. Risk of death from overdose of opioids rise four- to eightfold for doses above 100 mg/day. Recording Your Findings Recording Your Findings c dn u n n s Record the vital signs taken at the time of your examination. Scott is a young, healthy-appearing woman, well-groomed, fit, and in good spirits. He is alert, with good eye contact, but cannot speak more than two or three words at a time because of shortness of breath. For total scores between 3 and 5 points (moderate risk) or 6 points (high risk), further evaluation is needed (especially for the elderly). Accessed June 24, 2011; Office of Dietary Supplements, National Institutes of Health. Chapter 4 Beginning the Physical Examination 65 Table 4-5 Abnormalities in Rate and Rhythm of Breathing Normal. Many causes, including restrictive lung disease, pleural chest pain, and an elevated diaphragm. Kussmaul breathing, due to metabolic acidosis, is deep, but rate may be fast, slow, or normal. May be secondary to diabetic coma, druginduced respiratory depression, increased intracranial pressure. In infants and the aged, may be normal during sleep; also accompanies brain damage, heart failure, uremia, drug-induced respiratory depression. Clinicians often miss clues to trauma, mental illness, and harmful dysfunctional behaviors. Even for patients who obtain care, evidence suggests that adherence to treatment guidelines in primary care offices is <50%. Thirty percent of symptoms last more than 6 weeks and are "medically unexplained," masking anxiety, depression, or even somatoform disorders. Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. Without better "dual diagnosis," patient health, function, and quality of life are at risk. Mental Health Disorders and Unexplained Symptoms in Primary Care Settings Mental Health Disorders in Primary Care Approximately 20% of primary care outpatients have mental disorders, but up to 50% to 75% of these disorders are undetected and untreated. Roughly one-third of physical symptoms are unexplained; in 20% to 25% of patients, physical symptoms become chronic or recurring. In patients with unexplained symptoms, the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical symptoms, making detection and "dual diagnosis" important clinical goals. Common Functional Syndromes Co-occurrence rates for common functional syndromes such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity reach 30% to 90%, depending on the disorders compared. The prevalence of symptom overlap is high in the common functional syndromes: namely, complaints of fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems. The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy. For unexplained conditions lasting beyond 6 weeks, experts recommend brief screening questions with high sensitivity and specificity, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety. Many of the terms used to describe the mental status examination are familiar to you from social conversation. Take the time to learn their precise meanings in the context of the formal evaluation of mental status (see below). Terminology: the Mental Status Examination Level of Consciousness Attention Memory Alertness or State of Awareness of the Environment the ability to focus or concentrate over time on one task or activity the process of registering or recording information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years. Awareness of personal identity, place, and time; requires both memory and attention Sensory awareness of objects in the environment and their interrelationships; also refers to internal stimuli. Explore any unusual thoughts, preoccupations, beliefs, or perceptions as they arise during the interview. All patients with documented or suspected See Table 20-2, Delirium and Dementia, pp. Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling Screening for depression and suicidality Screening for alcohol, prescription drug, and substance abuse Mood Disorders and Depression. Lifetime prevalence of major depression meeting formal diagnostic criteria in the United States is approximately 7%. Primary care providers fail to diagnose major Chapter 5 Behavior and Mental Status 71 depression in up to 50% of affected patients, often missing early clues such as low self-esteem, anhedonia (lack of pleasure in daily activities), sleep disorders, and difficulty concentrating or making decisions. Failure to diagnose depression can have fatal consequences-suicide rates in patients with major depression are eight times higher than in the general population. Suicide rates are highest among men 75 years and older and are increasing among teenagers and young adults. More than half of patients committing suicide have visited their physicians in the prior month. More than 90% of suicide deaths occur in patients with depression or other mental health disorders or substance abuse. Risk factors include suicidal or homicidal ideation, intent, or plan; access to the means for suicide; current symptoms of psychosis or severe anxiety; any history of psychiatric illness (especially linked to a hospital admission); substance abuse; personality disorder; and prior history or family history of suicide. Patients with these risk factors should be immediately referred for psychiatric care and possibly hospitalization. The comorbidity of alcohol and substance abuse with mental health disorders and suicide are extensive. Alcohol, tobacco, and illicit drugs account for more illness, deaths, and disabilities than any other preventable condition. Lifetime prevalence of alcohol and illicit drug use in the United States is 13% and 3%. An estimated 3% are dependent on or abuse illicit drugs; of these, 60% use marijuana. Because screening for alcohol and drug use is part of every patient history, review the screening questions recommended in Chapter 3, Interviewing and the Health History. Test specific functions if indicated during the interview or physical examination. Aphasia, dysphonia, dysarthria, changes with mood disorders Testing for Aphasia Word Comprehension Ask patient to follow a one-stage command, such as "Point to your nose. For the fund of information, ask names of presidents, other political figures, or large cities. Calculating Abilities, such as addition, subtraction, and multiplication Abstract Thinking-ability to respond abstractly to questions about the meaning of proverbs, such as "A stitch in time saves nine" the similarities of beings or things, such as a cat and a mouse or a piano and a violin Constructional Ability. Ask patient: these attributes reflect intelligence, education, and cultural background. They are limited by mental retardation but are fairly well preserved in early dementia.
Amyloid deposits may be found in many other organs including liver infection mrsa generic cipro 1000mg amex, spleen antibiotics prostatitis buy cipro 500mg lowest price, gastrointestinal tract and thyroid gland can you drink on antibiotics for sinus infection buy generic cipro 750mg on line. These dogs may also be deaf Physiological conditions Schirmer tear test this breed has a lower average Schirmer tear test than others Average was 15 zithromax antibiotic resistance buy cipro 500mg mastercard. Amyloid deposits may also be found in adrenal and thyroid glands, spleen, stomach, small intestine, heart, liver, pancreas and colon. These deposits often do not contribute to the clinical signs which are principally due to chronic renal failure. Figure 16b M-mode echocardiogram (left ventricular short axis) of a fourteen-year-old neutered male Domestic Short Hair cat with hypertrophic cardiomyopathy. Most cases do not develop renal failure until later in life (average age 7 years). Most reported cases have been in this breed Geographic distribution: around the Mississippi, Ohio, Missouri, Tennessee, and St Lawrence Rivers, the southern Great Lakes, and the southern mid-Atlantic states. It appears to be inherited, but not in a simple way, with more than one gene thought to be involved. The lesion develops in the first three to eight weeks of life, and may be first detected as a heart murmur at this age. If the condition is mild, clinical signs are minimal, but more severely affected animals may suffer from weakness, collapse and sudden death. Atrial fibrillation this arrhythmia is usually seen in conjunction with severe heart disease such as dilated cardiomyopathy. Atrial septal defect this congenital condition, involving a defect in the septum between the atria, is uncommon, accounting for 14 out of 1000 cases in a survey of dogs with congenital heart disease. Small defects may be asymptomatic, but larger lesions can lead to congestive heart failure. Bypass tract macrore-entrant tachycardia of Labrador Retrievers this rare condition involves tachycardia caused by abnormal conduction within the heart. Canine juvenile polyarteritis syndrome Young Beagles from various laboratories have been reported to suffer from a pain syndrome caused by systemic vasculitis. Coronary artery vasculitis Spontaneous, asymptomatic coronary artery vasculitis has been documented in up to 34% of young Beagles studied. Endocardial fibroelastosis Severe thickening of the endocardium is seen in this condition, sometimes involving the mitral valve leaflets. This is the most common cause of heart disease in the dog, with up to 75% of dogs with congestive heart failure suffering from this condition. The heart valves become deformed by a myxomatous degeneration, leading to regurgitation and congestive heart failure. This condition is likely to be inherited, although other proposed causes include stress, hypertension, hypoxia, infection and endocrine abnormalities. In Greyhounds, a higher blood pressure compared to other breeds is a physiological condition, and the same may be true of Siberian Huskies, where a hereditary essential hypertension was reported in Husky crosses. Familial cardiomyopathy this is a form of dilated cardiomyopathy seen in English Cockers and other breeds. Hereditary stenosis of bundle of His this condition leads to an atrioventricular conduction block. Hypertrophic cardiomyopathy In this condition a hypertrophied ventricle causes congestive heart failure and dysrhythmias. It is likely that the condition is inherited, although modifying factors may cause variable expression of the condition. Mitral valve dysplasia this is the commonest congenital heart disease of cats, and is thought to be inherited in some Figure 17 An ultrasound machine capable of Doppler echocardiography is useful in the diagnosis of congenital cardiac abnormalities. Dilated cardiomyopathy (see figures 18a and 18b) this condition involves a dilation of the heart involving larger chamber size, thinner heart walls and reduced power of the heartbeat. It is thought that the majority of cases are genetic or familial, but it is not certain that all cases are genetic in origin. Nutritional abnormalities may also contribute, and it is possible that viral and immune-mediated causes may be involved in some cases. Figure 18b Dorsoventral thoracic radiograph of a ten-year-old female Domestic Short Hair cat with idiopathic dilated cardiomyopathy. The lesion consists of a malformation of the mitral valve, the normal function of which is to prevent blood flowing back from the left ventricle to the left atrium. Many animals with this condition do not show symptoms, and those that do usually demonstrate exercise intolerance and congestive heart failure. Patent ductus arteriosus the ductus arteriosus carries blood from the pulmonary artery to the aorta in the foetus to bypass the lung, which is not in use. It is probably the commonest congenital heart condition of dogs, but is less common in cats. Symptoms range from none, to congestive heart failure and poor body condition, to weakness, collapse and seizures. Pericardial effusion this condition involves a build up of fluid between the heart wall and the pericardium. The idiopathic form is poorly understood, and it is not known whether it is inherited. Symptoms are precipated by the inability of the heart to fill properly because of restriction caused by the fluid-filled pericardial sac. Chronic cases exhibit weight loss, ascites and dyspnoea resulting from pleural effusion. Peritoneopericardial hernia this uncommon congenital disease is seen in only about 0. It involves a continuation of the pericardium with the peritoneum, and often abdominal viscera are found within the pericadial sac. It may be asymptomatic, or may cause signs of respiratory distress, vomiting and colic. Persistent atrial standstill this is a rare condition caused by an enlargement and thinning of the atria. It is often Disease Summaries associated with scapulohumeral wasting in English Springers. Persistent left cranial vena cava the left cranial vena cava is normally present in the foetus, but may persist abnormally after birth. This abnormality is relatively common, but is of no significance to the animal unless it is undergoing thoracic surgery. Persistent right aortic arch this is a malformation in the foetal development of the vascular system, which leads to the oesophagus being partially occluded. Pulmonic stenosis this is a common congenital condition, affecting 20% of dogs diagnosed with congenital heart disease. The condition may be asymptomatic, or may cause signs of syncope and right-sided congestive heart failure. Sick sinus syndrome this dysrhythmia often involves periods of bradycardia and tachycardia, leading to syncope. Tetralogy of Fallot this condition accounts for approximately 4% of congenital heart disease. Pulmonic stenosis, ventricular septal defect, a dextrapositioned or overriding aorta and a secondary right ventricular hypertrophy comprise the four parts of this abnormality. Tricuspid dysplasia this is a malformation of the tricuspid valve, the consequence of which is to allow blood to flow back from the right ventricle into the right atrium. In some cases the animals are asymptomatic for many years, while others show progressive heart failure leading to death. Ventricular ectopy Ventricular ectopic beats are abnormal beats of the heart arising within the ventricles instead of the normal pacemaker in the atria. If they occur frequently they can cause symptoms of collapse, and the rhythm can degenerate into fatal ventricular fibrillation. Ventricular septal defect this condition accounts for approximately 7% of canine congenital heart disease. Small defects may be asymptomatic, but larger defects can cause congestive heart failure, pulmonary vascular disease and pulmonary hypertension. Alopecia areata this condition is uncommon, leading to an asymptomatic, non-inflammatory alopecia.
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Syndromes