Condet

Elizabeth A. Shaughnessy, MD, PhD

• Associate Professor
• Department of Surgery
• University of Cincinnati
• Surgeon
• University Hospital
• Cincinnati, Ohio

Reactive Depression: Reactive depression is commonest type of depression It may be caused by a reaction to external events such as loss of a loved one or a disaster medications gerd prometrium 100mg amex. It is not genetically determined or it does not occur in cycles or reoccur medications you can take when pregnant generic prometrium 200mg with mastercard, and it is usually milder than the endogenous depression treatment 4 sore throat cheap prometrium 200 mg amex. Endogenous depression (autonomous depression) Endogenous depression is due to some unknown origin or internal process symptoms of colon cancer generic prometrium 100mg with visa, and it is not associated with external events. Clinical features of depression Regardless of age the classification of depressions are more alike than different. Their clinical features include changes of mood, thought behavior and appearances. In addition depressives are often characterized by somatic symptoms as well as anxiety. Mood: Sad, unhappy, blue and crying Thought: Pessimism, ideas of guilt, self dislike loss of interest and motivation, decrease in efficiency and concentration. Behavior and appearance: Neglect of personal appearance Psychomotor retardation or agitation Somatic: Loss of appetite or voracious appetite Loss of weight or over weight Constipation Poor sleep (insomnia or hypersomnia) Aches and pains Menstrual change in female patients Loss of libido 64 Psychiatric Nursing Anxiety features: such as Palpitation Sweating Tremor Suicidal thoughts, threats and attempts or self destruction behavior etc Psychomotor retardation Agitation Not all these symptoms are likely to be observed in one person. Thus one person may show psychomotor retardation (general slowing down of movement, speech and thought disturbance) and another person may show agitation. The common signsare Sad face Stooped posture Crying at intervals Slow speech Dejected mood Diurnal mood variation Suicidal wishes Indecisiveness Hopelessness Inadequacy Conscious quiet Loss of interest 65 Psychiatric Nursing - Loss of motivation Fatigability Disturbed sleep (early morning awaking) Loss of appetite Constipation Treatment Amitriptyline (elavil) 75 - 200 mg/d in divided dose 1. Isolation, withdrawal, ambivalence, hostility, guilt or impaired thought processes are but a few symptoms that can interfere with the development of a therapeutic relationship. The nurse must be aware of personal vulnerability to depressive behavior: working with such persons may cause one to react to the depressed atmosphere and in turn experience symptoms of depression. The following is a list of attitudes that the nurse should display toward depressed and manic persons: 1. Body language may replace communication skill because the person is unable to convey feelings of anger, hostility and ambivalence. Questions the nurse can ask the patient to assess the level of depression, while observing facial expression, body posture, tone of voice, and overall appearance, include the following: 1. Protective care may be necessary for the manic as well as for the depressed person. Persons who exhibit manic behavior may injure themselves owing to excessive motor activity, inability to concentrate, distractibility and poor judgment. They also may provoke self-defensive actions unintentionally from others who fear injury. Assisting with electro convulsive or electric shock therapy is another nursing intervention while caring for depressed patients. Patient education is another nursing intervention for depressed and manic persons. Such persons should be informed about the 68 Psychiatric Nursing importance of outpatient treatment as well as the continuation of prescribed drugs. They should be taught to recognize the onset of side effects, as well as the recurrence of symptom, to avoid re-hospitalization. A person diagnosed as having bipolar depression, mixed type, should be helped to describe the changes in affect and behavior in the initial phases of his illness. The person may have difficulty expressing feelings of hostility, ambivalence, and guilt. The nurse can be supportive simply by making him or herself available to the patient and by recognizing symptoms such as anxiety. When approaching the person, avoid being overly cheerful, sympathetic or superficial. Set limits regarding time to arise in morning and the amount of time spent in bed during the day. Administer prescribed medication for insomnia Alterations in nutrition: Less than body requirements Monitor Input and output. Alteration in selfconcept Involve in activities directed toward raising selfesteem. Activity intolerance because of hyperactivity and distractibility Decrease or limit environmental stimuli.

Abstract Keywords: Sublingual swelling; Vascular hamartoma; Hemangioma; Lymphangioma Hamartoma is derived from the Greek word hamartia meaning fault or defect and -oma denoting tumor symptoms 6 days after iui buy generic prometrium 100mg line. It was coined by Albrecht in 1904 to denote developmental tumorlike malformation [1] keratin smoothing treatment cheap prometrium 200 mg amex. It is defined as a non neoplastic developmental malformation treatment uterine fibroids buy prometrium 100 mg mastercard, comprising of normal mature cells which are native to the anatomic location [1] symptoms 10 weeks pregnant generic 200 mg prometrium amex. Histology shows disorganized architectural pattern with predominance of one of its components. They are common in lung, pancreas, spleen, liver and kidney but very rare in the head and neck region. But morbidity can arise due to obstruction, infection, infarction, hemorrhage, and rarely due to neoplastic transformation. Deeper masses such as the mass described in this present case, can cause Respiratory and swallowing disturbance. Post-operative histopathological examination revealed it to be Vascular Hamartoma. Introduction the obstructive nature of the swelling has led to the child to develop difficulty in both respiration and swallowing, which has prompted the parents to come to the hospital. Bimanual palpation revealed a swelling in the floor of the mouth, 3 x 3 cm in size, ovoid in shape, bluish in colour, non-tender and firm in consistency. A provisional differential diagnosis of Ranula, Hemangioma, Lymphangioma, Pleomorphic Adenoma and Congenital Dermoid Cyst was made. We report a rare case of Vascular Hamartoma of the Sublingual Region masquerading as a Ranula. Presently, Case Report the risk of life threatening respiratory distress made surgery necessary. Through an external neck incision, swelling was identified on retracting the mylohyoid muscle. Thus defect in the regulatory pathway of vascular stem cells leads to formation of hamartomatous lesion [2]. They may occur as primary lesion or in association with syndromes such as Sturge-Weber, Klippel-Trenaunary, Proteus Syndrome, Bannayan-Riley-Ruvalcaba Syndrome and Osler-Weber-Rendu Syndrome. In patients less than 20 years of age, they represent 6% of all benign tumors of smooth tissue [3]. Clinically, lymphangiomas of the oral cavity present with a plaque made up of small vesicles with thin walls. In the case presented here, these plaques were observed on the lingual surface of the tongue. Hamartoma are usually exophytic but may rarely present as a flat pigmented lesions. According to a study conducted by Kaplan, though Hamartoma of the oral cavity is very rare, it may occur on the tongue, labial mucosa, buccal mucosa, and median maxillary alveolus. Ranula is a extravasation cyst of the sublingual gland which represents 6% of all oral sialocysts [4]. Post-Operative: Figure 2: Following dissection of the mass from the surrounding tissue. Histopathology: Ciliated vascular channels surrounded by fibro-collagenous tissue and skeletal muscle tissue. The floor of mouth swelling resolved and the cervical wound healed normally (Figures 3 & 4). It can also have massive involvement of the submandibular and parapharyngeal spaces. Its clinical and radiological behavior can be misleadingly similar to other cystic neck masses, particularly the cystic hygroma. But while lymphoid malformations such as Lymphangiomas are present at birth or early childhood, ranulas typically appear in young adults. Both are centered in the submandibular space with a possible continuous extension beneath the free edge of the mylohyoid muscle. Whereas Plunging Ranulas involve only the parapharyngeal and sublingual spaces, lymphangiomas are far more infiltrative, extending further toward the para- and retropharyngeal, carotid, posterior cervical and visceral spaces and the mediastinum.

The classic clinical constellation of hemochromatosis is a patient presenting with bronze skin symptoms vaginitis purchase 100 mg prometrium overnight delivery, diabetes when administering medications 001mg is equal to order prometrium 200 mg with amex, cardiac conduction abnormalities treatment 101 buy prometrium 200mg overnight delivery, and liver disease medicine x protein powder quality prometrium 100mg. Alcoholic liver disease and chronic excessive Fe ingestion may also be associated with a moderate increase in hepatic Fe and elevated body Fe stores. Clinical Features Early symptoms include weakness, lassitude, weight loss, a bronze pigmentation or darkening of skin, abdominal pain, and loss of libido. Diabetes mellitus occurs in about 65%, usually in pts with family history of diabetes. Diagnosis Serum Fe, percent transferrin saturation, and serum ferritin levels are increased. In an otherwise-healthy person, a fasting serum transferrin saturation > 50% is abnormal and suggests homozygosity for hemochromatosis. In most untreated pts with hemochromatosis, the serum ferritin level is also greatly increased. If either the percent transferrin saturation or the serum ferritin level is abnormal, genetic testing for hemochromatosis should be performed. All first-degree relatives of pts with hemochromatosis should be tested for the C282Y and H63D mutations. Liver biopsy may be required in affected individuals to evaluate possible cirrhosis or to quantify tissue iron. Death in untreated pts results from cardiac failure (30%), cirrhosis (25%), and hepatocellular carcinoma (30%); the latter may develop despite adequate Fe removal. Hemochromatosis Therapy involves removal of excess body Fe, usually by intermittent phlebotomy, and supportive treatment of damaged organs. Since 1 unit of blood contains ~250 mg Fe, and since 25 g of Fe must be removed, phlebotomy is performed weekly for 1­2 years. Less frequent phlebotomy is then used to maintain serum Fe at <27 mol/L (<150 g/dL). Chelation therapy is indicated, however, when phlebotomy is inappropriate, such as with anemia or hypoproteinemia. Each disorder causes a unique pattern of overproduction, accumulation, and excretion of intermediates of heme synthesis. The major manifestations of the hepatic porphyrias are neurologic (neuropathic abdominal pain, neuropathy, and mental disturbances), whereas the erythropoietic porphyrias characteristically cause cutaneous photosensitivity. Manifestations include colicky abdominal pain, vomiting, constipation, port-wine colored urine, and neurologic and psychiatric disturbances. Clinical and biochemical manifestations may be precipitated by barbiturates, anticonvulsants, estrogens, oral contraceptives, alcohol, or low-calorie diets. Acute Intermittent Porphyria As soon as possible after the onset of an attack, 3­4 mg of heme, in the form of heme arginate, heme albumin, or hematin, should be infused daily for 4 days. It is due to deficiency (inherited or acquired) of hepatic uroporphyrinogen decarboxylase. Photosensitivity causes facial pigmentation, increased fragility of skin, erythema, and vesicular and ulcerative lesions, typically involving face, forehead, and forearms. Porphyria Cutanea Tarda Avoidance of precipitating factors, including abstinence from alcohol, estrogens, iron supplements, and other exacerbating drugs, is the first line of therapy. A complete response can almost always be achieved by repeated phlebotomy (every 1­2 weeks) until hepatic iron is reduced. The skin manifestations differ from those of other porphyrias, in that vesicular lesions are uncommon. Redness, swelling, burning, and itching can develop within minutes of sun exposure and resemble angioedema. Protoporphyrin levels are increased in bone marrow, circulating erythrocytes, plasma, bile, and feces. Clinical Features Hepatic disease may present as hepatitis, cirrhosis, or hepatic decompensation. In other pts, neurologic or psychiatric disturbances are the first clinical sign and are always accompanied by Kayser-Fleischer rings (corneal deposits of copper). In about 5% of pts, the first manifestation may be primary or secondary amenorrhea or repeated spontaneous abortions. Diagnosis Serum ceruloplasmin levels are often low, and urine copper levels are elevated. Zinc treatment does not require monitoring for toxicity, and 24-h urine copper can be followed for a therapeutic response.

Syndromes

• Difficulties with speaking, chewing, or swallowing
• You touch your nose, eyes, or mouth after you have touched something contaminated by the virus, such as a toy or doorknob.
• Babies born at 27 weeks or later usually have their exam at 4 weeks of age.
• Cardiovascular complications (aortitis and aneurysms)
• Let your doctor know if you get a cold, flu, fever, herpes breakout, or other illness before your surgery.
• Take over-the-counter pain medications like acetaminophen or ibuprofen.
• Burns of the esophagus (food pipe)
• Hypopituitarism
• Excessive loss of minerals from bone
• MRI of the abdomen

If symptoms at 6 weeks pregnant prometrium 200 mg free shipping, however symptoms 0f food poisoning effective prometrium 100 mg, the oxygen deprivation lasts longer than 1 or 2 minutes treatment for vertigo generic prometrium 200 mg with visa, or if it is superimposed upon pre-existing cerebral vascular disease 9 medications that cause fatigue trusted 100mg prometrium, then stupor, confusion, and signs of motor dysfunction may persist for several hours or even permanently. Under clinical circumstances, total ischemic anoxia lasting longer than 4 minutes starts to kill brain cells, with the neurons of the cerebral cortex (especially the hippocampus) and cerebellum (the Purkinje cells) dying first. In humans, severe diffuse ischemic anoxia lasting 10 minutes or more begins to destroy the brain. In rare instances, particularly drowning, in which cold water rapidly lowers brain temperature, recovery of brain function has been noted despite more prolonged periods of anoxia, although such instances are more common in children than adults. Thus, resuscitation efforts after drowning (particularly in children) should not be abandoned just because the patient has been immersed for more than 10 minutes. Equally low arterial blood oxygen tensions have been reported in conscious humans who recovered without sequelae. These laboratory findings suggest that guaranteeing the integrity of the systemic circulation offers the strongest chance of effectively treating or preventing hypoxic brain damage. Acute, short-lived hypoxic-ischemic attacks causing unconsciousness are most often the result of transient global ischemia caused by syncope (Table 5­8). Much less frequently, transient attacks of vertebrobasilar ischemia can cause unconsciousness. Such attacks may be accompanied by brief seizures, which often present problems in differential diagnosis as seizures themselves cause loss of consciousness. Syncope or fainting results when cerebral perfusion falls below the level required to supply sufficient oxygen and substrate to maintain tissue metabolism. Among young persons, most syncope results from dysfunction of autonomic reflexes producing vasodepressor hypotension, so-called neurocardiogenic, vasovagal, or reflex syncope. Vasodepressor responses remain the predominant cause of syncope in older persons as well, but with advancing age, syncopal attacks are more likely to Multifocal, Diffuse, and Metabolic Brain Diseases Causing Delirium, Stupor, or Coma 213 Table 5­8 Principal Causes of Brief Episodic Unconsciousness* 1. Reflex from visceral sensory stimulation (deep pain, gastric distention, postmicturition, etc. Visceral sensory stimulation (tracheal stimulation, glossopharyngeal neuralgia, swallow syncope, etc. Carotid origin emboli in the presence of severe vascular disease of other cervical cranial arteries 2. Condition 3 often is so brief (especially if the head falls below the level of the heart, resulting in improved cerebral blood flow) that neither subject nor observer can be sure whether full consciousness was retained. In conditions 4 and 5, the patient may appear awake and ``conscious' to observers, but has no exact memory of the episode and often recalls it simply as an unconscious attack. Vasodepressor syncope is usually heralded by a brief sensation of giddiness, weakness, and sweating before consciousness is lost. This is an important diagnostic point if present, but about 30% of patients with true syncope may be amnesic from the loss of consciousness and thus report the episode as a ``drop attack'149 (see below). Reflex syncopal attacks almost always occur when the victim is in the standing position, rarely when sitting, and almost never when prone or supine. Asystole, on the other hand, characteristically produces unheralded, abrupt unconsciousness regardless of position. The brevity of the unconsciousness, the rapid restoration of wakefulness when the head is at position equal to or lower than the heart, and the appearance of pallor prior to and during the loss of consciousness differentiate asystolic syncope from transient vertebrobasilar insufficiency. Drop attacks, defined as sudden collapse of the legs in someone who is standing resulting in a fall, generally occur in middle-aged150 and older adults. Others are otologic in origin,152 although the patient is sometimes unaware of vertigo. Occasionally drop attacks occur as a result of bilateral ischemia of the base of the pons or the medullary pyramids, or as a result of transient, positional compression of the upper cervical spinal cord due to atlantoaxial subluxation or fracture of the dens. Vertebrobasilar transient ischemic attacks produce short-lived neurologic episodes characterized by symptoms of neurologic dysfunction arising from subtentorial structures, especially vertigo, nausea, and headache154 (Table 5­9). Brief confusion or amnesic episodes sometimes occur, but stupor and coma are rare, perhaps because ischemia sufficient to affect such a large part of the brainstem bilaterally generally causes additional signs of brainstem ischemia. Basilar ischemia involving the descending motor pathways in the basis pontis or the medullary pyramids sometimes results in drop attacks, which may superficially resemble asystolic syncope. The absence of either unconsciousness or the physical appearance of circulatory failure differentiates the condition from true syncope. Epileptic seizures may occasionally be difficult to distinguish from syncope as a cause of unconsciousness. Patient 5­7 A 39-year-old woman with a primary brain tumor was doing well after radiation and chemotherapy when, without warning, she had a generalized convulsion.

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