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- Professor, Neurology UCSF Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA
When it has been and purchase 4mg singulair amex asthmatic bronchitis joke, on the rupture of a cyst 10mg singulair overnight delivery asthmatic bronchitis untreated, a macular hole may be absorbed discount singulair 5 mg otc asthma symptoms bronchial asthma, the rupture best singulair 10 mg asthma 10 code, usually not far from the disc, concen formed. This appears clinically as a round or oval, deeply tric with it and on its temporal side, is seen as a curved red patch, as if a hole has been punched out. In the stage of white streak over which the retinal vessels pass and which cyst formation some central vision may remain, but if a rapidly becomes pigmented along its edge (Fig. Retinal breaks can be induced and are commonly su Sometimes multiple ruptures occur, more or less concentric peronasal dialyses caused by differential traction at the with each other. Retinal detachment may occur slowly, weeks loss of central vision results, but simple ruptures in which to months later. Direct trauma at the equator can rarely the macula is not involved cause little impairment of cause tears or atrophic retinal breaks. These are treated conservatively with steroids to also be precipitated in eyes already suffering from myopia decrease infammatory changes and the extent of later cho or other peripheral retinal degenerations. Occasionally, particularly in concussion injuries associ A contusion may also cause a choroidal or supra ated with gunshot wounds, a rupture of the retina is associ choroidal haemorrhage. Such cases present a characteristic picture of traumatic proliferative chorioreti nopathy secondary to haemorrhage into the vitreous, leading Retina to traction bands. The retina may suffer oedematous or degenerative changes, Prognosis should be guarded in all cases of serious be torn, or haemorrhages may occur in it. Commotio Retinae (Berlin Oedema) Optic Nerve this is a common result of a blow on the eye. A milky white cloudiness due to oedema appears over a considerable area the optic nerve may be injured in fractures of the base of at the posterior pole which may sometimes disappear after the skull by fragments of the optic canal. Avulsion although vision may be good at frst, central vision gradu of the optic nerve is very rare in civilian life but occurs in ally diminishes, the loss of function being associated gunshot wounds of the orbit. Haemorrhages of the optic with the development of pigmentary deposits at the macula. Intraocular Pressure this may be seriously disturbed following concussion inju ries, particularly if they are severe. Angle recession is associated with traumatic effects on the outfow channels leading to an insidious glaucoma. Ghost cell obstruction of the trabeculae in long-standing vitreous haemorrhages may also induce a secondary glaucoma. Such glaucoma may be controlled by medication, but is sometimes intractable even to operative treatment. The patient should immediately have an eye to cause chorioretinal adhesions and prevent future retinal shield applied and be thoroughly examined under general detachments. Evaluation for repair should be done at the same Occasionally in a corneal wound caused by a dirty im time. The gravity of such injuries is due to the immediate plement or vegetable matter, pyogenic organisms are carried damage to the eye, post-traumatic iridocyclitis (a common into the eye, multiply there and cause rapid necrosis of sequel to a perforating wound), the introduction of infection the entire cornea. In these cases a ring of deep infltration and sympathetic ophthalmitis, one of the most dreaded com appears 2 or 3 mm internal to and concentric with the plications of perforating wounds. If the organism is Pseudomonas aeruginosa (an anaerobic Gram negative rod), there is extensive chemosis of the conjunctiva, Wounds of the Conjunctiva sometimes with a greenish discharge. Enzymes released Wounds of the conjunctiva are common and should be by the organism cause liquefaction of the cornea. The institution of intensive treatment with appropriate local and systemic antibiotics and a thera Wounds of the Cornea and Sclera peutic keratoplasty may occasionally save such eyes. The margins swell up If it fnds access into the anterior chamber, pyogenic soon after the accident and become cloudy due to accumu infection leads to a purulent iridocyclitis with hypopyon, lation of fuid, thus facilitating closure of the wound and endophthalmitis and usually panophthalmitis. If small and limited to the centre, corneal wounds heal well unless they become Wounds of the Lens infected, in which case treatment is like that of a perforating ulcer (Fig. Such wounds cause traumatic cataract and are always a If the wound is large, an adhesion of the iris or its serious complication. In small recent injuries, the entry of aqueous causes a localized cloudiness in its the prolapsed iris should be replaced with the help of intra vicinity and, irrespective of the site of the wound, opacities ocular miochol or pilocarpine and the wound repaired with in the form of feathery lines appear in the posterior cortex, 10-0 nylon sutures. If the iris appears non-viable, it must which later develop into a rosette-shaped cataract resem be abscised and the edges of the wound sutured directly re bling that of early concussion cataract (Fig. Occa placing fxed anatomical landmarks such as the limbus into sionally the wound in the capsule becomes sealed, particu continuity frst and then suturing anteriorly and posteriorly as larly if a posterior synechia develops, in which case these required. However, they usually progress limbus are sutured completely after a thorough exploration. The integrity of the They are also treated with surrounding cryoapplications posterior lens capsule must be assessed pre-operatively so that appropriate surgery is planned. If the lens is damaged, it rapidly opacifes and focculent grey masses protrude through the opening in the capsule, sometimes flling the whole chamber. A traumatic cataract of this type is liable to lead to serious complications if not aspirated at once. The swelling of the lens keeps the iris in contact with the cornea and a secondary glaucoma may ensue. The treatment of traumatic cataract in association with penetrating wounds, especially if complicated by vitreous loss, is by the use of a vitrectomy instrument. The aim of surgery is to remove the cataract, perform an adequate vitrectomy, suture the globe as a primary procedure, and insert an intraocular lens in suitable cases. Adequate steps are essential to ensure control of infec tion and infammation by intraocular and topical antibiotics and steroids. They excite a virulent panophthalmitis with Mechanical Effects a brownish discharge and gas bubbles in the anterior cham ber. Although they are sensitive to penicillin, destruction of the foreign body may enter the eye through either the vision has always followed.
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There is a clear power diferential in the relationship between patient and doctor buy singulair 10mg visa asthma symptoms just before giving. In particular generic 10mg singulair with mastercard asthma symptoms red cheeks, people presenting for counselling or any type of psychological therapy are often at their most vulnerable buy discount singulair 5 mg online asthma like bronchitis. The transference of fattering feelings and impulses onto the doctor—respect for authority buy singulair 5mg amex asthma definition and pathophysiology, attraction to power and success, desire for approval— may tempt the doctor into abusing his or her power. To exploit such a position to fulfl ones own needs is unethical and potentially damaging to patients. For professional therapists, it is prohibited to have intimate relations even after therapy has fnished. Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries. They may begin with the acceptance of expensive gifts, fnancial or stock broking advice, or even betting tips. Appointments may be made that are longer than usual, or regularly scheduled A Manual of Mental Health Care in General Practice 11 at the end of the day when other staf members have left the practice. This may progress to the performance of unnecessary physical examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations. Doctors who are vulnerable to boundary transgressions include those experiencing life crises, in particular those with problems in their own marriages or personal relationships. Perfectionists1 who are excessively self-sacrifcing and work unnecessarily long hours may have difculty setting limits on the demands of certain patients and begin taking extraordinary measures in attempt to rescue them. Patients with histories of sexual abuse may be particularly prone to evoke such countertransference responses, especially when they express recurrent suicidal ideation. Doctors who deny their dependency needs and give the appearance of being self-contained may be prone to seeking gratifcation for their needs for love and nurturance through their patients: while denying their own dependency needs, they may perceive others as being dependent on and needy of them. A doctor sufering a psychosis might violate professional boundaries as a consquence of the illness. Psychopathic doctors who wilfully exploit patients for the gratifcation of their own needs have no place in the medical profession. Understanding versus explanation In formulating a person’s problems, we seek to answer the question, ‘Why does this individual feel, think and act this way at this time We understand a person’s experience when, through listening to his or her story and clarifying the experience, we are able to empathise with him or her and to imagine how we might feel under similar circumstances. For example, we understand the grief of the bereaved, the anger of someone who is frustrated, the guilt of the person who has hurt another and the shame of someone who has done something foolish. We can also understand the meaning of an event for that person, and we can look for reasons why he or she feels that way. We can understand the grief of the bereaved, the anger of someone who has been frustrated, the guilt of the person who has hurt someone else, and the shame of someone who has done something foolish. For example, there is no understandable reason for the memory loss of someone with dementia. Instead, we seek an explanation in terms of a cause—in this case, a disruption in brain physiology and a loss of brain substance. Similarly, we cannot understand how a person with schizophrenia starts hearing voices. Instead, we seek explanations in terms of neurotransmitters, abnormalities in information processing and other physical causes. For example, you might understand why a high-achieving man becomes depressed following a myocardial infarction. However, this should not stop you from diagnosing major depression if his depressed mood persists and he expresses feelings of worthlessness and guilt, and suicidal ideation. Although a problem may be understandable, its treatment may require pharmacological or other physical interventions. Since all mental disorder is both a disorder of mind and of the brain, it is always possible to both understand and explain diferent aspects of the same problem. The grief of a bereaved woman will be refected in biochemical and other events in her brain. However, the fact that her reaction is clearly understandable indicates that our initial treatment would be through grief counselling. If her grief is prolonged, and she begins to sufer prominent and distressing feelings of guilt, and is contemplating suicide, we would use an anti-depressant drug as an adjunct to the grief work. Similarly, in the case of a man with schizophrenia, although we may not be able to understand the evolution of his auditory hallucinations (the form of his experience), we may be able to empathise with their content. We can also empathise with his reactions to the disability and handicap that he sufers as a consequence of the illness. For the person with dementia, the feelings of loss, fears about the future, and the change to a more dependent role are all issues that are understandable and amenable to psychotherapy and counselling. While the form of a delusion proper is not understandable, it is often possible to empathise with its content. The dialectical principle In the philosophy of Hegel, dialectics is a process in which a proposition is made (thesis), then negated (antithesis), and fnally replaced by a new proposition that resolves the confict between the two (synthesis)1. Although this may seem a little obscure, this way of thinking is common in making decisions about mental health problems. You will often have to make choices between apparently contradictory propositions. Always consider the possibility that the best course of action lies in a synthesis of the two. In psychiatry, the best solution to a problem is often a synthesis of two apparently contradictory possibilities. Impairment, disability and handicap When assessing people with mental health problems, it is useful to classify their complaints as impairments, disabilities or handicaps. Disability is any restriction or lack in ability to perform an activity normal for a human being.
Other forms of acting out include coming late to buy singulair 4 mg on line asthma definition quantitative therapy sessions or missing them altogether quality singulair 5 mg asthma definition unity, calling the ther apist in the middle of the night order 4 mg singulair visa asthma vomiting, or making suicidal threats or gestures cheap 4mg singulair with mastercard asthma questions. In this case the therapist might say, “I think you are going to the bar and drinking to excess because you are trying to numb yourself to the negative emotions that you are beginning to experience in our therapy together. Interpersonal therapy is centered on the concept that interpersonal attachments are essential for survival and emotional well-being and that loss of interpersonal relation ships causes depression. Interpersonal therapy postulates four interper sonal problem areas: complicated mourning, interpersonal role disputes (conflicts with a significant other), role transition (any change in life status that can cause distress), and interpersonal deficits (lack of social skills). After an initial diagnostic evaluation and a detailed exploration of the patient’s current relationship and social functioning, the therapist links the depressive symptoms with the patient’s interpersonal situation in the framework of one of the four interpersonal problem areas. The therapy process then focuses on current problems and on what goes on in the patient’s life outside the office. Anxiety rapidly rises when the patient is prevented from performing the neutralizing compulsive behavior (eg, washing hands after touching a contaminated object), but subsequently it declines (extinction). Extinction refers to the progressive disappearance of a behavior or a symptom (in this case, anxiety) when the expected consequence does not happen (getting sick because of contamination). This page intentionally left blank Mood Disorders Q uestions Questions 286 and 287 286. A 30-year-old woman presents to the psychiatrist with a 2 month history of difficulty in concentrating, irritability, and depression. Three months prior to her visit to the psychiatrist, the patient noted that she had experienced a short-lived flu like illness with a rash on her calf, but has noted no other symptoms since then until the mood symptoms began. Prozac for depressed mood (ie, treat the depressed mood only) 169 170 Psychiatry Questions 288 and 289 288. A 37-year-old woman comes to the physician with a chief complaint of a depressed mood. The patient states she has anhedonia, anergia, a 10-lb weight loss in the last 3 weeks, and states she “just doesn’t care about any thing anymore. Which of the following physiologic disturbances will likely also be found in this patient After 1 week of the medication, no improvement is seen and the dosage is raised to the maximum recommended level. For how many weeks should this new dosage be maintained before determining that the drug trial is unsuccess ful if there is no improvement shown She notes over the next week that she has become irritable and is not sleeping very well. She worries that her child will die and fantasizes that if the child died, she would kill herself as well. Over the course of the following week, she begins to investigate how she might commit suicide and calls a friend to see whether the friend will babysit so that the woman will not be leaving the child alone should this occur. A 25-year-old man comes to the psychiatrist with a chief complaint of depressed mood for 1 month. His mother, to whom he was very close, died 1 month ago, and since that time he has felt sad and been very tearful. He has difficulty concentrating, has lost 3 lb, and is not sleeping soundly through the night. A 32-year-old woman is brought to the emergency room by the police after she was found standing in the middle of a busy highway, naked, commanding the traffic to stop. In the emergency room she is agitated and restless, with pressured speech and an affect that alternates between euphoric and irritable. The resident on call decides to start the patient above on a medication to control this disease. The patient refuses the medication, stating that she has taken it in the past and it causes her to be constantly thirsty and break out in pimples and makes her food taste funny. A 28-year-old woman is diagnosed with bipolar disorder, manic type, when she was hospitalized after becoming psychotic, hypersexual, severely agitated, and unable to sleep. Which of the following medications, recom mended for acute use in manic patients, is recommended to be continued on into maintenance therapy A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He notes poor self-esteem and low energy, and feels hopeless about his situation, though he denies suicidal ideation. A 26-year-old man comes to the physician with the chief complaint of a depressed mood for the past 5 weeks. He has been feeling down, with decreased concentration, energy, and interest in his usual hobbies. Six weeks prior to this office visit, he had been to the emergency room for an acute asthma attack and was started on prednisone. How long after a stroke is a patient at a higher risk for developing a depressive disorder A 22-year-old college student calls his psychiatrist because for the past week, after cramming hard for finals, his thoughts have been racing and he is irritable. The patient has been stable for the past 6 months on 500 mg of valproate twice a day. Which of the following is the most appropriate first step in the management of this patient’s symptoms A 24-year-old woman, 5 days after delivery of a normal, full-term infant, is brought to the obstetrician because she is so tearful.
Exacerbation of Emotions: Melancholia order singulair 5mg with amex asthma symptoms utility index, Mania 5 mg singulair asthma natural treatment, Ecstasy In affective disorders generic singulair 4 mg fast delivery asthma treatment besides inhalers, the mood is usually the primary focus of the abnormality buy generic singulair 4mg asthma symptoms worse at night. In sadness, this may present as feel ings of sadness and gloom, despondency, despair or hopelessness. Often, the actual experience is indescribable but recognized as different in character from normal sadness. Jamison (1995) described her personal experience of mania: When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars and you follow them until you fnd better and brighter ones. Shyness goes; the right words and gestures are suddenly there, the power to captivate others a felt certainty. Sensuality is pervasive and the desire to seduce and be seduced is irresistible But somewhere this changes Everything previously moving with the grain is now against – you are irritable, angry, frightened, uncontrollable, and enmeshed in the blackest caves of the mind. It is clear that the positive, joyful aspect of the elevation of mood can quickly turn into a dysphoric sensation that is uncomfortable and unwelcome, yet that is not a variant of depression. Euphoria is a state of excessive unreasonable cheerfulness; it may be manifested as extreme cheer fulness, as described above in mania, or it may seem inappropriate and bizarre. It is commonly seen in organic states, especially associated with frontal lobe impairment. Heightened states of happiness such as ecstasy sometimes occur in people with mental illness or abnormality of personality. Understandably, most psychiatrists writing about the mood state of ecstasy have described its occurrence in patients with psychosis. But ecstatic experience may also be reported in association with minor psychiatric symptoms. The patient may describe a calm, exalted state of happiness amounting to ecstasy, although this tranquil mood state is rela tively uncommon and usually short-lived. In schizophrenia, ecstatic mood may be associated with exalted delusions, for example, the chronic patient who sat placidly enraptured on a long-stay ward, knowing herself to be the Queen of Heaven and waiting for a messenger to inform her that she was to take over the rule of the world. Ecstatic states, usually with a histrionic favour, may occur in dissociative disorder and may be associated with religious stigmata (Simpson, 1984). Bizarre, mass hysterical phenomena, often with religious associations, are usually of this type, for example in the devils of Loudun as described by Aldous Huxley (1952). Ecstasy, solemn elation or excessive exuberant expansiveness may also be seen in epilepsy and in other organic states, for example in general paresis. Characteristic of ecstasy is that it is self-referent; for example, the fowers of spring ‘open for me’. There is an alteration of the boundaries of self so that the person may feel ‘at one with the universe’, or he may ‘empty myself of all will’ so that ‘I am nothing but feelings’. The change in ego boundaries does not usually have the aspect of interference with self that accompanies pas sivity experiences. Expert knowledge of the abnormal does not preclude ignorance of the normal, and the psychiatrist can never generalize from the sample of people selectively referred to him to the whole of mankind. This discrepancy can become very obvious in the area of ecstatic and religious experience. There is a need to acknowledge, take into account, have respect for and use in treatment the patient’s own subjective experience in this area (Sims, 1994). The psychiatrist sees a most unrepresentative group of those having some form of religious experience, which has been considered to amount to over 40 per cent of the adult population of the United States of America, more of whom are males than females, more are stable than unstable and more happy than unhappy. The anthropology of ecstasy (Lewis, 1971) can be traced through Christian and other cultures and makes contact with recognizable mental illness only at a few points. William James (1902), in the Variety of Religious Experience, demonstrated the vast extent of the phenomenology of religion and showed how unwise it would be to equate the surprising with the pathological. Accounts vary as to the extent of psychopathology among converts to religious groups and sects; it is probably associated with the nature of the group. Thus Ungerleider and Wellisch (1979) found no evidence of severe mental illness in one study, while Galanter (1982) described evidence of emotional problems among adherents to Divine Light, the Unifcation Church, Baba and Subud. Suggestive indicators for establishing a religious experience as probably associated with psy chiatric morbidity are: the phenomenology of the experience conforms with psychiatric illness there are other recognizable symptoms of mental disturbance the lifestyle, behaviour and direction of personal goals of the person subsequent to the event are consistent with the natural history of mental disorder rather than with an enriching life experience such behaviour is consistent with disorders in the person’s personality. With the following signs, the experience is more likely to be intrinsic to the person’s belief and less likely to denote psychiatric illness: the person shows some degree of reticence to discuss the experience, especially with those he anticipates will be unsympathetic; it is described unemotionally with matter-of-fact conviction and appears ‘authentic’; the person understands, allows for and even sympathizes with the incredulity of others; he usually considers that the experience implies some demands on himself; the religious experience conforms with the subject’s recognizable religious traditions and peer group. Ecstatic states can be conceptualized as an altered state of consciousness and can be self induced in meditation adepts. Jhanas are an example of such a self-induced meditative state characterized by dimming of the awareness of external experience, fading of internal verbaliza tions, alteration in the sense of personal boundary, intense focus on the object of meditation and increase in joy. This state has been shown to be associated with the activation of cortical processes and of the nucleus accumbens in the dopamine/opiod reward system (Hagerty et al. These two basic emotions can occur in pure form but can also complicate the intensifcation of sadness or joy, so that it is not uncommon for depressed or elated mood to be associated with anxiety or irritability. Morbid surprise is seen in latah, a culture-bound disorder described in Malaysia in which there appears to be an exaggerated startle response characterized by a myriad of echo phenomena including echolalia, echopraxia and echomimia. There is also coprolalia, automatic obedience and hypersug gestibility (Bartholomew, 1994). Hyperekplexia is a heightened startle refex that occurs either as a hereditary neurological condition involving the inhibitory glycine receptor, or as a symptomatic disorder predominantly of epilepsy in which a surprise stimulus provokes a normal startle response that then triggers a focal, usually frontal lobe, seizure (Meinck, 2006).
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