By J. Kurt. Southeastern Bible College.
Increased risk factors include older mothers purchase clarithromycin 250mg on line, but most infants are born to younger mothers buy clarithromycin 500mg with visa. The syndrome is characterized by craniofacial abnormalities 500mg clarithromycin visa, cardiac defects, gastrointestinal abnormalities, hypothyroidism, acute leukaemia, depression and dementia in about 45% of those >40 yrs. Fortunately, within the last 40 years we have moved from institutional models of care, with the closure of long-stay institutions to models of care which promote social inclusion and ordinary living. Support services are based on community inclusion, using concepts such as social role valorization and increased self-determination. Good communication will include spoken language, non-verbal communication such as facial expression, body language and gestures and any written forms of communication. Considerations should also be made to ensure that communication is culturally appropriate with increased use of interpreters versus reliance on family members. Communication skills of people with intellectual disabilities can be divided as following: -pre-verbal: this means that people do not have the cognitive abilities to understand words: they have profound and multiple learning difficulties; they can be helped to understand through routines, tone of voice, repetition, the context of the situation, objects and their own experience. These include the familiarity with the context or the person speaking, guessing or understanding of speaker’s non-verbal cues such as body language, facial expression and gestures or signing. As we know non-verbal communication is very powerful and people gain around 55% of the information through body language and 38% through the tone, pitch and intonation, leaving only 7% to the actual verbal language information. Use lots of non-verbal feedback, especially head nods and facial expression to show that you are listening. Closed questions, that are yes/no questions, are often not helpful as people may answer “yes” because they think you want them to say yes. Either/or questions may be easier, but keep them short, so that they do not just repeat the last thing you say, for example, “do you like tea or orange juice? Check what language the person is most comfortable with and whether you would need an interpreter. They might use learnt phrases or echo what is being said or what they have heard from past experiences. Therefore, diagnosis depends on the interaction of a number of factors such as what the person says they are experiencing, what others say about them, how they are seen to behave and the history of their complaint. They have also difficulties understanding questions so questions should be asked in simple language, using short sentences, appropriate to the adult’s developmental level. The assessment may need to be repeated, and longer periods of time may be needed for answers to be given and understood. While minimizing the tendency to acquiescence is a skill that has general applicability to any psychiatric interview, it is particularly important in this population. The attitude of anyone being interviewed is likely to be influenced by expectations of the interaction. It is therefore important for the interviewer to maximise the patient’s confidence and sense of security by extensive explanation of the purpose of the interview as well as constant reassurance. Therefore it is important to recapitulate and summarize previously stated material. This has the benefit of re-engaging and focusing the patient’s attention as well as giving an opportunity to collect more detail, in addition to allowing the patient to agree or disagree with the interviewer’s interpretation of what has been said. If doubt exists about the meaning of responses, it is very important to clarify with the help of a carer or family member who knows the patient well. Obsessional symptoms: it is very difficult to obtain a clear description of obsessions being the product of a person’s own mind, for example. Resistance is often found to be minimal, especially if the obsessions are long-standing. It is also significant to remember that the content of the delusional beliefs is usually developmentally appropriate for the person’s overall ability. Sometimes, beliefs that, on the surface, appear to be delusional, may simply be a reflection of overall cognitive development of the patient. In general, complex psychotic symptoms such as delusional perceptions are infrequently found, due to the difficulty in eliciting such phenomena in people with limited verbal and intellectual skills. A careful assessment, with collateral information, will help distinguish these presentations. A functional analysis of behaviour is frequently needed to ensure accurate diagnosis. Diagnosis and Diagnostic Classification Assessment aims not only to detect the presence of psychiatric illness and make a diagnosis, but also to identify the features that make a person vulnerable to them. Any therapeutic interventions must take into account a number of factors, including the patient’s wishes, the diagnosis and vulnerability factors including psychological (for instance characteristic ways of thinking), biological (such as genetic predisposition or medication) and social (including environmental factors). Some of these vulnerability factors (such as brain damage) cannot be changed, but others (such as an optimal control of Epilepsy) can and should form part of the care plan. Many of the factors are the same as in the general population and it is their interaction that is important in creating the particular vulnerability to developing mental illness. It is also essential that the development and delivery of clinical services hold what is known as prevention and minimization of those disturbances. Bizarre velocardiofacial syndrome behaviours and adaptive regression can occur Bipolar Affective More common than general It can be diagnosed whatever the degree of Disorder population disability. Recording behavioural correlates of mood can help to establish the cyclical nature of the disorder, and be used to monitor treatment. Dementia More prevalent than in general Psychotic symptoms and epilepsy may be a population (14% v.
Differential diagnosis of ectopic pregnancy • Appendicitis • Salpingitis • Ovarian torsion • Threatened abortion • Gastroenteritis • Urinary tract infection in early pregnancy • Urolithiasis in early pregnancy • Dysfunctional uterine bleeding • Normal intrauterine pregnancy • Corpus luteum cyst • The presence of a palpable adnexal mass or fullness with associated tenderness is present in up to two-thirds of patients however its absence does not rule out the possibility of an ectopic pregnancy generic clarithromycin 500 mg line. Uterine decidual tissue casts may be passed in 5-10% of patients and can be mistaken for tissue from a spontaneous abortion clarithromycin 250 mg amex. In the case of ec- topic pregnancy rupture discount clarithromycin 250mg otc, peritoneal signs may be present on abdominal examination secondary to hemoperitoneum. In the unruptured ectopic pregnancy, the vital signs are more likely to be normal. Rupture of an Ectopic Pregnancy • Rupture of an ectopic pregnancy is associated with: • syncope • sudden onset of severe pelvic/abdominal pain • hypotension • When an ectopic pregnancy ruptures, there occurs hemorrhage into the peritoneal cavity leading to peritoneal signs. A progesterone level >25 ng/ml is consistent with a viable intrauterine pregnancy with a 97. Lower levels however do not reliably correlate with the location of the patient’s pregnancy. Initial values may be normal, however a low Hg/Hct initially or an acute drop over the first several hours is concerning when considering the possibility of ectopic pregnancy in your differential diagnosis. May be helpful for identifying other potential entities in your differential diagnosis once ectopic pregnancy has been ruled out. The possible options are laparoscopy with appropriate surgical intervention if an ectopic pregnancy is identified. Indications for methotrexate usage in ectopic pregnancy • Ectopic pregnancy unruptured and <3. The procedure is done by aspiration of the con- tents from the pouch of Douglas entered by way of the posterior fornix. The aspira- tion of nonclotting blood is considered a positive test that is suspicious for ectopic pregnancy. Vaginal Bleeding in the First Half of Pregnancy Forty percent of pregnant patients present with some degree of vaginal bleeding 7 during early pregnancy. The vast majority of these spontaneous abortions occur prior to 8 wk of gestation. At least half of all spontaneous abortions are due to genetic abnormali- ties; the rest being due to a combination of factors such as uterine abnormalities, incompetent cervix, progesterone deficiency, tobacco or alcohol use. Once again, one must always consider ectopic pregnancy in the differential when evaluating the pregnant patient with vaginal bleeding. The patient with unilateral pelvic pain and vaginal bleeding needs thorough evaluation to differentiate early abortion from ectopic pregnancy. Definitions • Threatened Abortion—Uterine bleeding in the first 20 wk of pregnancy without any passage of tissue or cervical dilatation. These patients present with vaginal bleeding in the first half of pregnancy 90% of the time. Diagnostic Evaluation • Standard laboratory testing to be obtained in the setting of vaginal bleeding in the first half of pregnancy should include all of the following. Patients with a visualized intrauterine pregnancy with a closed cervical os can be considered to have a threatened abortion. Correlation of ultrasound results with the patient’s history and physical findings will allow the type of abortion to be identified. They should be instructed to return to the Emergency Department if vaginal bleeding increases and/or returns, if they notice any passage of tissue, or if they de- velop significant pelvic pain or fever. The patient should be placed on pelvic rest which means no intercourse, no douching and physical activity. Vaginal Bleeding in the Second Half of Pregnancy Vaginal bleeding after 20 wk of gestation can present a complicated clinical management situation with the lives of the mother and fetus often both in serious jeopardy. Abruptio Placentae/Placental Abruption • Definition—The complete or partial placental separation from the decidua basalis (uterine implantation site) after 20 wk of gestation. When this separation develops, 7 blood vessels are ruptured leading to hematoma formation which leads to significant hemorrhaging and fetal hypoxia. Incidence • Abrubtio placentae occurs in approximately 1/100 pregnancies and is the cause of approximately 14% of all stillbirths in the United States. Clinical Presentation • Variability of clinical presentation is related to the quantity and location of hemor- rhaging. The patient may complain of back and/or abdominal pain, and the pain is usually relatively sudden in its onset and constant in nature. Early awareness of this possibility may become apparent if the patient is noted to have excessive hemorrhaging at venopuncture or intravenous access sites, mucosal/gingival hemorrhaging, easy bruising and/or hematuria. Emergency Department Management • Intravenous access should be immediately obtained. Causes of vaginal bleeding in the 2nd half of pregnancy • Abruptio placentae/placental abruption • Placenta previa • Premature labor • Premature rupture of membranes • Lesions of the cervix and lower genital tract • Uterine rupture • Vasa previa Table 7A. Risk factors for placental abruption • Hypertension • Preeclampsia • History of prior placental abruption • Trauma • Cigarette smoking • Increasing maternal age 7 • High multiparity • Illicit drug use (cocaine abuse) • Excessive alcohol consumption • A Kleihauer-Betke test should also be obtained to detect fetal cells in the maternal circulation. When abruption is visualized on ultrasound it appears as a hypoechoic area between the placenta and the uterine wall. In the presence of more severe placental abruption, expedited vaginal delivery or emergent cesarean section may be necessary. Placenta Previa Definition • Placenta previa describes a situation where any part of the placenta implants in the lower uterine segment and be associated with a high risk of significant serious mater- nal hemorrhaging. Risk factors for placenta previa • Multiparity • Multiple gestation pregnancies • Previous cesarean section • Prior uterine scar for any reason • Increasing maternal age • Previous abortion • Prior placenta previa • Diabetes mellitus • Erythroblastosis fetalis • Any process that increases placental size • Marginal Placenta Previa—The placenta is located adjacent to the patient’s internal os but is not covering it. Incidence • Placenta previa occurs in approximately 1/200 pregnancies in the United States. Emergency Department Management • When placenta previa is clinically suspected emergent obstetrical consultation should be obtained.
Features indicative of Patient positioning difﬁcult airway rescue are equally important to recognize (Box 6 purchase clarithromycin 500mg overnight delivery. Conscious patients will maintain themselves in the optimum posi- It is vital that these features are identiﬁed early in the assessment tion to maintain their airway and drain secretions/blood 250mg clarithromycin with amex. This process as they may guide the level of intervention undertaken in position should be maintained where possible and the patient the ﬁeld and/or trigger early transfer to hospital for deﬁnitive airway should not be forced to lie supine purchase 250mg clarithromycin. In unresponsive spontaneously H History of previous airway difﬁculties breathing trauma patients, the lateral trauma position (Figure 6. A stiff neck collar is applied in the supine position (receding mandible, large tongue, buck teeth, high arched palate) and the patient log-rolled into the lateral position. O Opening of the mouth <3 ﬁngers T Trauma – maxillofacial injury, burns and airway bleeding Suction Correct positioning with postural drainage is more important than suction in the presence of gross liquid contamination of the airway, Box 6. Hand-held suction units Mask Seal Difﬁculty – Beard/Facial trauma should only be used as a back-up as they are less effective. Restricted mouth opening (less than 4–5cm/3 ﬁngers) Obstruction at the larynx or below Distorted airway – affects seal e. In Trauma (laryngeal)/Tumours extremis a surgical airway may be used to bypass the obstruction. Facial fracture reduction Airway management Bilateral mandibular fractures can result in an unstable anterior Fortunately, most patients in the prehospital setting have a patent segment which can displace backwards obstructing the airway. In patients with Manually lift the displaced fragment forward to relieve the obstruc- a compromised or threatened airway, immediate action is needed. Maxillary (Le Fort) fractures can result in a mobile mid-face Prehospital care should start with simple, basic manoeuvres such as segment which may displace backwards obstructing the airway. To the chin lift or jaw thrust, proceeding to more complex measures if reduce, the mobile segment should be grasped between the thumb simple procedures prove insufﬁcient. The level of intervention will and the index/middle ﬁnger (inserted into the patients mouth) and be determined by the practitioner’s skillset (Figure 6. Simultaneous applicationofafacemaskcapableofdeliveringoxygenorventilation is possible with this technique. The appropriate size is equivalent to the distance between the incisors to the angle of the jaw (Figure 6. In children under 4 years the airway should be inserted equal to the distance between the nostril and the angle of the jaw. Profuse soft-tissue bleeding from the nasal reﬂex, as it may provoke vomiting and laryngospasm. They are particularly useful in patients with limited mouth ventilation is required as part of a failed airway drill, a combination opening, e. After lubrication it should inserted through the nostril, along the ﬂoor of the nasal cavity and into the upper airway until stopped by the ﬂange (Figure 6. As their name implies they are not designed to be inserted beyond the vocal cords into the trachea. A major disadvantage, 0 Small Child though, is that they do not fully protect the lower airways against aspiration of gastric contents, secretions or blood. This risk must 1 Child be weighed against the ease of use and potential life-saving beneﬁts 2 Small Adult in the prehospital arena. Such devices can provide a life-saving solution to a severe airway problem, especially when endotracheal intubation skills are not available. Endotracheal intubation Endotracheal intubation is potentially harmful in unskilled hands and undetected oesophageal intubation may be fatal for the patient. The procedure should be drug assisted (see Chapter 9) unless the patient is in cardiac arrest or deeply unconscious with an absent gag reﬂex. The age-appropriate size and type of laryngo- scope blade and endotracheal tube are listed in Box 6. GlideRite®) are preferred as they are less traumatic and less liable to catch on the laryngeal cartilages on insertion. Laryngoscopes are notoriously unreliable and a secondary handle and blade should be available in case of failure of the primary device. Most of the 2–4 years 2 Miller (Age/4) + 4 modern devices have an oesophageal drainage channel through Uncuffed which a nasogastric tube can be inserted and the stomach con- 4–9 years 2 Miller/Mackintosh (Age/2) + 12 9–16 years 3 Mackintosh (Age/4) + 3. Airway Assessment and Management 25 It is imperative to optimize intubation conditions in order to Every system should have a written, and well rehearsed, ‘failed increase the rate of ﬁrst pass success (Box 6. Where conditions intubation plan’ for use in the event of failure of the 30-second are suboptimal (e. Direct visualization of the tube passing through the cords is be employed should the initial laryngoscopic view be suboptimal. Auscultation is then performed ﬁrst These form the basis of the ‘30-second drills’ – 30 seconds being in the epigastric area, then in both axillae. Cricoid pressure should be oesophagus it will bubble violently in this area in synchrony with releasedasthereislimitedevidencetosayitisbeneﬁcialbuthasbeen your bag–valve–tube ventilation. If that happens, the patient must shown to impair laryngoscopic view if performed poorly. Therefore always auscultate the epigastric area used to elevate the epiglottis and improve the view at laryngoscopy ﬁrst. Measurement of the end-tidal carbon dioxide using waveform in difﬁcult intubations (e. A number of options are available for securing the correctly placed endotracheal tube.
Among those with cirrhosis order 250 mg clarithromycin free shipping, 1% to 4% annually may develop hepatocellular carcinoma buy clarithromycin 500mg. Therapy is directed toward reducing the viral load to prevent the sequelae of end-stage cirrhosis generic 250mg clarithromycin visa, liver failure, and hepatocellular car- cinoma. Currently, the treatment of choice for chronic hepatitis C is combi- nation therapy with pegylated alpha-interferon and ribavirin. However, the therapy has many side effects, such as influenzalike symptoms and depression with interferon, and hemolysis with ribavirin. The goal of interferon therapy for hepatitis C is preventing the complications of chronic hepatitis. Cirrhosis is the end result of chronic hepatocellular injury that leads to both fibrosis and nodular regeneration. With ongoing hepatocyte destruction and collagen deposition, the liver shrinks in size and becomes nodular and hard. Alcoholic cirrhosis is one of the most common forms of cirrhosis encountered in the United States. It is related to chronic alcohol use, but there appears to be some hereditary predisposition to the development of fibrosis, and the process is enhanced by concomitant infection with hepatitis C. Loss of functioning hepatic mass leads to jaundice as well as impaired synthesis of albumin (leading to edema) and of clotting factors (leading to coagulopathy). Fibrosis and increased sinusoidal resistance lead to portal hypertension and its complications, such as esophageal varices, ascites, and hypersplenism. Portosystemic shunting via natural collaterals or iatrogenic shunts causes hepatic encephalopathy. Hepatic encephalopathy is characterized by mental status changes, aster- ixis, and elevated ammonia levels. The most common cause of ascites is portal hypertension as a conse- quence of cirrhosis. The pathogenesis involves a combination of decreased effective circulatory blood volume because of portal hypertension (underfill theory), inappropriate renal sodium retention leading to expansion of plasma volume (overfill theory), and decreased plasma oncotic pressure. When not caused by portal hypertension, ascites may be a result of exudative causes such as infection (eg, tuberculous peritonitis) or malignancy. The patient usually presents with abdominal swelling and demonstration of free fluid by physical examination or imaging procedures such as ultrasonography. It is important to try to determine the cause of ascites in order to look for reversible causes and for serious causes, such as malignancy, and to guide therapy. Ascitic fluid is obtained by paracentesis and examined for protein, albumin, cell count with differential, and culture. The treatment of ascites usually consists of dietary sodium restriction cou- pled with diuretics. Loop diuretics are often combined with spironolactone to provide effective diuresis and to maintain normal potassium levels. Spontaneous bacterial peritonitis is a relatively common complication of ascites, thought to be caused by translocation of gut flora into the peritoneal fluid. Symptoms include fever and abdominal pain, but often there is paucity of signs and symptoms. However, fluid cultures, when posi- tive, usually reveal a single organism, most often gram-negative enteric flora but occasionally enterococci or pneumococci. This is in contrast to secondary peri- tonitis, for example, as a consequence of intestinal perforation, which usually is polymicrobial. Empiric therapy includes coverage for gram-positive cocci and gram-negative rods, such as intravenous ampicillin and gentamicin, or a third-generation cephalosporin or a quinolone antibiotic. Comprehension Questions For the following questions choose the one cause (A-G) that is probably responsible for the patient’s presentation: A. Idiopathic or autoimmune hepatitis is a less-well-understood cause of hepatitis that seems to be caused by autoimmune cell- mediated damage to hepatocytes. Diabetes mellitus, cirrhosis of the liver, hypogonadotrophic hypogonadism, arthropa- thy, and cardiomyopathy are among the more common end-stage developments. Skin deposition of iron leads to “bronzing” of the skin, which could be mistaken for a tan. Diagnosis is made early in the course of disease by demonstrating elevated iron stores but can be made through liver biopsy with iron stains. Sclerosing cholangitis is an autoimmune destruction of both the intrahepatic and extrahepatic bile ducts and often is associated with inflammatory bowel disease, most commonly ulcerative colitis. Patients present with jaundice or symptoms of biliary obstruction; cholangiography reveals the characteristic beading of the bile ducts. Primary biliary cirrhosis is thought to be an autoimmune disease leading to destruction of small- to medium-size bile ducts. Most patients are women between the ages of 35 and 60 years, who usually present with symptoms of pruritus and fatigue. An alkaline phos- phatase level elevated two to five times above the baseline in an oth- erwise asymptomatic patient should raise suspicion for the disease. The inability to excrete excess copper leads to deposition of the mineral in the liver, brain, and other organs. Patients can present with ful- minant hepatitis, acute nonfulminant hepatitis, or cirrhosis, or with bizarre behavioral changes as a result of neurologic damage. Kayser- Fleischer rings develop when copper is released from the liver and deposits in Descemet membrane of the cornea.