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By: Z. Silvio, M.A., M.D.

Vice Chair, Stanford University School of Medicine

Remember to anxiety psychiatrist trusted 25 mg phenergan move major health events to anxiety level scale purchase genuine phenergan on-line the Present Illness or Past History in your write-up anxiety keeping me up at night cheap phenergan 25mg with mastercard. If the patient has only a few symptoms, this combination can be efficient but may disrupt the flow of both the history and the examination. Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, fever. Rashes, lumps, sores, itching, dryness, color change; changes in hair or nails; changes in size or color of moles. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Nose and sinuses: Frequent colds, nasal stuffiness, discharge or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums; bleeding gums; dentures, if any, and how they fit; last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Intermittent claudication; leg cramps; varicose veins; past clots in veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of urinary stream, hesitancy, dribbling. Sexual habits, interest, function, satisfaction, birth control methods, condom use, problems. Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction, problems (including dyspareunia). If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms. Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness. Nervousness; tension; mood, including depression, memory change, suicide attempts, if relevant. Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo; fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or "pins and needles," tremors or other involuntary movements, seizures. The Physical Examination: the Physical Examination: e i a n to Approach and Overview Approach and Overview r c n e e Conduct a comprehensive physical examination on most new patients or patients being admitted to the hospital. For more problem-oriented, or focused, assessments, the presenting complaints will dictate which segments you elect to perform. The key to a thorough and accurate physical examination is a systematic sequence of examination. Apply the techniques of inspection, palpation, auscultation, and percussion to each body region, but be sensitive to the whole patient. Minimize the number of times you ask the patient to change position from supine to sitting, or standing to lying supine. Note that clinicians vary in where they place different segments, especially for the musculoskeletal and nervous systems. Think through your approach, your professional demeanor, and how to make the patient comfortable and relaxed. Chapter 1 Overview: Physical Examination and History Taking 9 Reflect on Your Approach to the Patient. If you forget to do part of the examination, this is not uncommon, especially at first! Ask the patient to move toward you if this makes it easier to do your physical examination.

Syndromes

  • Scurvy
  • Infection, including in the lungs, urinary tract, and chest
  • Visible object in the ear
  • Decreased motion of the shoulder joint
  • Dysarthria - care
  • Medicines need to be given through a vein (IV)
  • Stiff neck (meningismus)
  • Thickening of the uterus

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Expansion of the spinal cord from T9-10 to anxiety symptoms in spanish purchase 25mg phenergan amex L1-2 caused by the greater supply region for the lower limbs anxiety symptoms in 12 year olds discount phenergan online amex. Tapered termination of the spinal cord at the level of L1-2 where it becomes continuous with the filum terminale anxiety quizlet generic 25mg phenergan with mastercard. Thin terminal prolongation of spinal cord attached inferiorly to the posterior surface of the coccyx. Thickening of the subarachnoid connective tissue within the posterior median sulcus, less in the cervical region, more in the thoracic segment. Longitudinal groove external to the boundary between the lateral and posterior funiculi. F Spinal cord 273 8 1 2 3 10 9 4 5 6 A Spinal meninges 7 8 14 3 4 5 6 2 2 2 9 10 11 7 12 B Roof of thomboid fossa (fourth ventricle) 13 14 C Choroidal plexus of lateral ventricles 23 24 20 15 16 21 15 16 18 10 17 18 19 11; 17 11; 17 22 19 20 21 22 23 24 25 a a a D Spinal cord E Lower termination of spinal cord F Cross section of spinal cord 274 Spinal cord 1 2 1 Funiculi of spinal cord. Three columns of white matter segmented by the posterior and anterior horns and their root fibers. Consists of myelinated nerves and is organized into three cords (funiculi) which contain the nerve pathways. Con- 15 duction bundle located between the anterior median fissure and the anterior horn with its root fibers. Conduction bundle located lateral to the gray matter 17 and between the posterior and anterior spinal nerve roots. Posterior column situated between the posterior horn with its root fibers and the posterior median septum. Here, the spinal cord segments are defined as regions where root fibers pass through a specific intervertebral foramen. Eight cervical segments represent the seven cervical vertebrae because the root fibers of segments 1-7 exit above the vertebrae of the same number. The cervical portion of the spinal cord extends from the atlas to the middle of C7. The 12 segments comprising 23 this group extend from the middle of C7 to the middle of T11. Comprised of five segments; it extends from the middle of the body of T11 to the upper border of the body of L1. In transverse section, it is seen as an H-shaped column (columna grisea = gray column) consisting primarily of multipolar ganglion cells and enclosed by white matter. Sections of the spinal cord reveal that the "horns" (cornua) which correspond to the gray column S are characteristically different in the individual segments. Situated anterolaterally in the anterior horn, it is localized in segments C4-8 and L2- S1 and innervates the muscles of the limbs. From its anteromedial position in the anterior horn, it extends the entire length of the spinal cord. It lies posterior to the anterolateral nucleus in segments C5-T1 and L2-S2 and innervates the muscles of the limbs. From the vicinity of the white matter, it extends over segments T1-L3 and probably innervates the trunk musculature. It lies in segments C1-6 in the area of the anterolateral nucleus and provides the root fibers of the spinal portion of the accessory nerve. D 21 22 23 24 25 13 Spinal cord 275 4 1 2 3 12 13 14 3 4 13 2 5 6 7 6 8 A Spinal cord, schematic 9 10 11 7 12 13 16 17 14 15 16 17 18 19 20 B Gray matter of spinal cord, three-dimensional 8 9 10 26 (24) 22 21 23 19 20 12 18 21 22 25 23 24 C Segments of spinal cord D Nuclei of spinal cord in anterior horn 25 a a a 276 Spinal cord 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Posterior column. A C rior horn in the lower cervical and thoracic spi20 Anterior fasciculi proprii. Thinner segment of posterior horn bethese bundles comprise longer and shorter tween the head and base. Fibers of the reflex apparatus located substance above the apex of the posterior horn. It consists primarily of glia and small ganglion 22 Anterior corticospinal (pyramidal) tract. Substantia crossed portion of pyramidal tract lateral to the visceralis secundaria.

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Managed care offers the potential to anxiety symptoms paranoia buy phenergan 25 mg line efficiently use resources and ultimately shift from costly delivery models to anxiety symptoms panic attacks purchase discount phenergan on line less costly anxiety symptoms all day purchase 25mg phenergan visa, coordinated prevention focused delivery models. A great deal of attention will need to be given to the potential impact of any proposed system wide change for children with a severe illness to ensure that they are cared for in an appropriate manner. Body mechanics for parents and care givers the musculoskeletal system is composed of bone, muscles, and joints, as well as their associated ligaments and tendons, which work together to permit movement. Defects within the system are a major cause of decreased motor ability in childhood. Practicing good body alignment and movement is also a part of providing a safe environment by preventing injury to your child and to yourself. Alignment is defined as the proper relationship of the body segments to one another. Balanced posture means a body that is stable, steady, and not likely to tip or fall, including the ligaments and muscles being used effectively. Various terms are used to describe body movements: Flexion ­ bending a joint as in the elbow Extension ­ straightening out a joint like a knee Abduction ­ to move an extremity away from the midline of the body Adduction ­ to bring an extremity back to the midline of the body Body Mechanics is the use of proper posture and body movements that are necessary in order to limit stress and strain on the musculoskeletal structures. Proper posture and the use of body mechanics are based upon the alignment and functioning with the 65 following four principles: Using the larger and stronger muscles to perform heavy work 66 67 68 69 70 71 72 73 74 75 76 77 Maintaining the center of gravity of the body close to the center of the base of support Keeping the combined center of gravity of the aide and your child centered within the base of support Having a base of support that is of the appropriate size and shape An essential ingredient in maintaining a healthy back for the care provider is proper body mechanics in the various activities of daily life. With regard to the back, proper body mechanics means using the body and the different parts of the body in ways that are consistent with the smooth functioning of the joints, muscles, ligaments, disks, and other structures of the back. Among other things, this means knowing how to lift and carry heavy objects properly, not holding your back in a fixed position for prolonged periods, and being careful never to twist the trunk when reaching for something. As with proper posture, proper body mechanics can significantly reduce the risk of many back problems. Although they represent slightly different ways of thinking, posture and body mechanics are closely related phenomena. Proper body mechanics will allow for smooth functioning of your joints, muscles, tendons, and ligaments. The more your child builds healthy routines in his/her life, the more they become simple habit and the less they seem like work. The following are the brain regions which control different activities: Caudate which governs affect, impulse control, and executive function Thalamus which is involved with sensory integration 78 Cerebellum which is involved in motor planning Hippocampus which directs memory and attention Superior temporal gyrus which directs language Cerebral cortex which directs goal-directed behavior and working memory 1. A weak heart means early fatigue and long term decline in your level of activity and independence; osteoporosis ­ your bones lose density from lack of use; weight gain ­ calories turn to fat when you do not burn them off with exercise. Diet ­ a variety of whole foods with minimal processing is the best source of nutrients needed by the body. Vitamin A is for growth and repair of body tissues and maintenance of healthy skin, derived by the body from carotene ­ carrots, green leafy vegetables and broccoli b. Vitamin C plays a role in the healing of wounds by maintaining collagen, the protein that forms connective tissue in the body; also helps fight bacterial infections; found in fresh fruits and vegetables d. Vitamin D maintains intestinal reabsorption and metabolism of Calcium and Phosphorus levels in the blood and bone; also maintains renal (kidney) reabsorption; essential for normal 79. This places nonambulatory children with seizure disorders at increased risk for fractures Calcium most abundant mineral in the body; it must be accompanied by Vitamin A, Vitamin C and Vitamin D, as well as, Magnesium and Phosphorus; it is crucial to bones and teeth and proper functioning of muscles (including the heart, which can not contract and release without Calcium); best source of Calcium is dairy products, but also found in fruits, vegetables and grains, especially figs, greens, and soy products Iron exists in every living cell; it works with Protein and Copper to carry oxygen from the lungs to the tissues of the body; found in liver, oysters, lean meat, molasses, and green leafy vegetables Potassium is involved in maintaining the water balance of cells which is necessary for cell growth and to stimulate nerve impulses to muscles; it also stimulates the kidneys to eliminate toxins from the body; Potassium is found in all vegetables, oranges, whole grains, sunflower seeds, potatoes and bananas Zinc is a crucial nutrient for wheelchair users because of its importance of blood formation and the skin, particularly in the healing of wounds. It is naturally found in meats, eggs, liver, seafood, legumes, nuts, peanut butter, milk, and wholegrain cereals Carnitine ­ a naturally-occurring amino acid found in skeletal muscle, essential for long chain fatty acid oxidation when impaired fat utilization and energy production is present. Blood work should be done periodically to check the Carnitine level if on this medication 80 3. Skin care to prevent pressure sores which develop from oxygen and blood being restricted in skin tissues by the weight of the body pressed continuously on a small area of skin a. Avoid unnecessary areas of pressure, especially the knees, buttocks, sacral bones (pelvis), ensuring proper fit and contact with braces, catheters and clothing b. Do exercises regularly and movement for pressure relief by shifting position and weight. Do not wear loose undergarments (wrinkles can cause increased pressure in small areas) h. Eat a balanced diet rich in nutrients for skin health ­ proteins, Vitamin A, Vitamin B Complex, Vitamin C, and Zinc; drink plenty of water to keep tissues moist and flexible 4.

Diseases

  • Mental retardation Wolff type
  • Weaver-like syndrome
  • Diverticulosis
  • Tracheoesophageal fistula
  • Optic nerve coloboma with renal disease
  • Sclerosing cholangitis
  • Diplopia, binocular
  • Camptocormism
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