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Co-Director, Cleveland Clinic Lerner College of Medicine
Nature Intensity Duration Stability of abnormal mood Risk of suicide Possible findings (1) Happiness (2) Elation (3) Depression (4) Anxiety (5) Anger (6) Indifference Thought and perceptions 1 anxiety means lexapro 10mg line. Possible findings (1) Loosening of associations (2) Flight of ideas (3) Incoherence (4) Confabulation (5) Blocking 2 anxiety keeps me awake order generic lexapro on-line. Possible findings (1) Obsessions (2) Compulsions (3) Delusions (4) Feelings of unreality 3 anxiety zone hypochondria purchase 10 mg lexapro otc. United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 6 Patient Assessment: 3 Techniques of Physical Examination: 2 1 depression youtube cheap 20 mg lexapro with visa. Insight into illness Level of judgement in making decisions or plans Possible findings a. Pallor United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 7 Patient Assessment: 3 Techniques of Physical Examination: 2 E. Ease of walking (1) Balance (2) Limp (3) Discomfort (4) Fear of falling (5) Abnormal motor pattern Dress, grooming and personal hygiene 1. Shoes (1) Clean (2) Holes cut in them United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 8 Patient Assessment: 3 Techniques of Physical Examination: 2 J. Unusual jewelry (1) Copper bracelet for arthritis Medical identification insignia (2) g. Hair, fingernails and use of cosmetics (1) Reflect lifestyle, mood, and personality (2) Grown out hair or nail polish my indicate decreased interest in appearance or help to estimate length of illness h. Is grooming and hygiene appropriate for the patients age, lifestyle, occupation and socioeconomic group Inspect and palpate the skin (1) Note the following characteristics (a) Color i) the red color of oxyhemoglobin and pallor due to lack of oxygen are best seen where the epidermis is thinnest ii) the fingernails and lips and the mucous membranes of the mouth and palpebral conjunctiva iii) In dark skinned persons, the palms and the soles may also be useful (b) Moisture (c) Temperature (d) Texture (e) Mobility and turgor (f) Lesions United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 9 Patient Assessment: 3 Techniques of Physical Examination: 2 B. Inspect and palpate the fingernails and toenails (1) Note their color and shape (2) Note if there are any lesions present c. The head (1) the scalp (a) Part the hair in several places (b) Look for scali ness, lumps or other lesions (2) the skull (a) Observe the general size and contour of the skull (b) Palpate and inspect note any tenderness, deformities or lumps (3) the face (a) Note the facial expression and contours (b) Observe for asymmetry, involuntary movements, masses and edema (4) the skin (a) Observe the skin (b) Note color, pigmentation, texture, thickness, hair distribution and any lesions b. The eyes (1) Methods to assess visual acuity (a) Print (b) Finger count at a distance (c) Distinguish light and dark b. The ears (1) the auricle Inspect each auricle and surrounding tissue for deformities, (a) lumps and skin lesions, drainage, tenderness, erythema (2) Mastoid (a) Discoloration (b) Tenderness (4) Assess gross auditory acuity United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 12 Patient Assessment: 3 Techniques of Physical Examination: 2. General approach (1) Have the patient expose their chest so that you can see the entire chest (2) Proceed in an orderly fashion (a) Inspect (b) Palpate (c) Percuss (d) Auscultate (e) Compare side to side (3) Try to visualize the underlying lobes of the lungs United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 13 Patient Assessment: 3 Techniques of Physical Examination: 2 b. The arterial pulse (1) Heart rate (2) Rhythm Amplitude (3) (4) Bruits and thrills b. General approach Ideally, the patient should not have a full bladder (1) (2) Make the patient comfortable in a supine position (3) Before palpation ask the patient to point out any areas of pain - examine these areas last (4) Have warm hands, a warm stethoscope and short nails (5) Approach slowly and avoid quick, unexpected movements (6) Distract the patient as needed with conversation Visualize each organ as in the region as you are examining (7) (8) Proceed in an orderly manner (a) Inspection (b) Auscultation (c) Percussion (d) Palpation b. Inspection of the abdomen, including the flanks, noting (1) Skin (a) Scars (b) Striae (c) Dilated veins (d) Rashes and lesions (e) Discoloration (f) Ascites (g) Herniation (2) the umbilicus (a) Contour (b) Location Signs of inflammation or hernia (c) (3) the contour of the abdomen (a) Bulges i) Flat ii) Rounded iii) Protuberant iv) Scaphoid v) Bulges at the flanks vi) Hernias (b) Symmetry (4) Peristalsis (5) Pulsations (6) Ascites c. Auscultate (1) Listen for bowel sounds (a) Note frequency and character i) Increased ii) Decreased iii) Absent United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 16 Patient Assessment: 3 Techniques of Physical Examination: 2 F. General approach (1) this may be awkward or uncomfortable for the patient and the provider (2) Male examiners are customarily attended by female assistants (3) Female examiners may choose to work alone b. Examination (1) Inspect the external genitalia (2) Note any (a) Inflammation (b) Discharge (c) Swelling (d) Lesions 4. General approach (1) this may be awkward or uncomfortable for the patient and the provider (2) Female examiners are customarily attended by male assistants (3) Male examiners may choose to work alone b. Examination (1) Inspect the external genitalia (2) Note any Inflammation (a) (b) Discharge (c) Swelling (d) Lesions 4. Can be accomplished with the patient in one of several positions (1) For most patients, the side-lying position is satisfactory (2) Drape the patient appropriately (3) Inspect the sacrococcygeal and perineal areas (a) Look for and note d. United States Department of Transportation National Highway Traffic Safety Administration Paramedic: National Standard Curriculum 17 Patient Assessment: 3 Techniques of Physical Examination: 2 i) Lumps ii) Ulcers iii) Inflammations iv) Rashes v) Excoriations vi) Tenderness (4)Methods for testing for occult blood I. General approach (1) Direct your attention to function as well as structure (2) Assess general appearance, bodily proportions and ease of movement (3) Note particularly (a) Limitation in the range of motion (b) Unusual Increase in the mobility of a joint (4) In general note Signs of inflammation (a) Swelling i) ii) Tenderness Increased heat iii) iv) Redness v) Decreased function (b) Crepitus (c) Deformities (d) Muscular strength (e) Symmetry (f) Atrophy b.
The two major categories of psychogenic unresponsiveness are those that result from a conversion disorder (often called conversion hysteria) and those that are part of the syndrome of catatonia (often thought to be a manifestation of schizophrenia) anxiety supplements proven 5mg lexapro. The two clinical pictures differ somewhat bipolar depression quiz online buy 10mg lexapro amex, but both may closely simulate delirium mood disorder nos 504 plan order lexapro with american express, stupor anxiety medication 05 mg order 20mg lexapro mastercard, or coma caused by structural or metabolic brain disease. The diagnosis of psychogenic unresponsiveness of either variety is made by demonstrating that both the cerebral hemispheres and the brainstem-activating pathways can be made to function in a physiologically normal way, even though the patient will seemingly not respond to his or her environment. The physician must recognize that with the exception of factitious disorders and malingering, psychologically produced neurologic symptoms are not ``imaginary. Interestingly, those feigning paralysis exhibited hypofunction of the right anterior prefrontal cortex when compared with controls. A patient studied during catatonic stupor showed hypometabolism in a large area of the prefrontal cortex including anterior cingulate, medial prefrontal, and dorsolateral cortices when compared with controls. Many physicians associate conversion reactions with a hysterical personality (conversion hysteria) but, in fact, conversion reactions may occur as a psychologic defense against a wide range of psychiatric syndromes, including depressive states and neuroses. The respiratory rate and depth are usually normal, but in some instances the patient may be overbreathing as another manifestation of the psychologic dysfunction (hyperventilation syndrome). The pupils may be slightly widened, but are equal and reactive except in the instance of the individual who self-instills mydriatic agents. Oculocephalic responses may or may not be present, but caloric testing invariably produces quick-phase nystagmus away from the ice water irrigation rather than either tonic deviation of the eyes toward the irrigated ear or no response at all. It is the presence of normal nystagmus in response to caloric testing that firmly indicates that the patient is physiologically awake and that the unresponsive state cannot be caused by structural or metabolic disease of the nervous system. In some patients, the eyes deviate upward (or sometimes downward) when the eyelids are passively opened. The slow, steady closure of passively opened eyelids that occurs in many comatose patients cannot be mimicked voluntarily. Patients suffering from psychogenic unresponsiveness as a conversion symptom usually offer no resistance to passive movements of the extremities although normal tone is present; if an extremity is moved suddenly, momentary resistance may be felt. However, the weight of the upper arm sometimes pulls the hand away from the face, giving the appearance of voluntary avoidance. The abdominal reflexes are usually present and plantar responses are invariably absent or flexor. Upon admission she was reportedly unresponsive to verbal command, but when noxious stimuli were administered she withdrew, repetitively thrust her extremities in both flexion and extension, and on one occasion spat at the examiner. She was given 10 mg of diazepam intravenously and 500 mg of phenytoin intravenously in two doses 3 hours apart. Eight hours later, because she was still unresponsive, a neurologic consultation was requested. She lay quietly in bed, unresponsive to verbal commands and not withdrawing from noxious stimuli. Her respirations were normal; her eyelids resisted opening actively and, when they were opened, closed rapidly. Her extremities were flaccid with Psychogenic Unresponsiveness normal deep tendon reflexes, normal superficial abdominal reflexes, and flexor plantar responses. When 20 mL of ice water was irrigated against the left tympanum, nystagmus with a quick component to the right was produced. She recovered full alertness later in the day and was discharged a day later with her neurologic examination having been entirely normal. Comment: this patient illustrates a common problem in differentiating ``organic' from psychogenic unresponsiveness. She had been sedated and had a mild metabolic encephalopathy, but the preponderance of her signs was a result of psychogenic unresponsiveness. She was awake and alert at the time of admission and had a normal neurologic examination.
During archival processing1 mood disorder hallucinations buy cheap lexapro 5mg line, barrier sheets are often inserted in albums to protect acid migration from pages to materials on a facing page depression jewelry generic 10 mg lexapro otc. Syn: alkali Notes: For paper documents depression urban dictionary buy cheap lexapro 10 mg on-line, paper is the base that supports the ink depression symptoms stomach upset purchase 5 mg lexapro fast delivery, graphite, or other material that forms the words or images of the content. Photographs may use paper, transparent or opaque plastic, ceramic, glass, metal, cloth, or other materials as a base to support the light-sensitive chemicals that form the image. A group of materials distinguished from similar materials by some characteristic, such as time of manufacture, receipt, or activity. Manufacturers may mark batches with identifying numbers and may also indicate the nature of variations from a standard. For example, some color photographic films indicate how each batch diverges from a neutral color balance so that photographers can use filters to correct for that variation. A method of entering and sorting transactions to ensure that a master file is updated or queried in a specific order. Notes: If the original is available, a copy generally will not be allowed as evidence in a trial. The rules allow the admission of copies, notes, or testimony under certain circumstances. Best practices do not guarantee success; rather, they describe those tactics and strategies used in successful companies. A document that analyzes and structures details about the formal elements of the materials, such as creator, title, dates, extent, and contents, to facilitate the identification, management, and understanding of the work. Bibliographic description emphasizes the transcription of information found in the materials being described, although the bibliographer or cataloger may supply some explanatory notes. A document proposing new law or changes to existing law for consideration by members of a legislative body. Notes: the file may include copies of bills, reports, staff memos, correspondence, secondary informational material, committee prints, and printed hearings and transcripts of executive session hearings. A substance used to hold disparate components together in a solid or to give even consistency to a liquid. Notes: Examples of binder4 include gelatin or collodion used to bind the metallic silver that forms a photographic image to the base, or the substance that holds the magnetized metal particles in an audio tape to a base. The process of securing the leaves or groups of pages (signatures) between covers to form a book. A genre of print that shows the buildings and streets of a city or town from an oblique, aerial perspective. A fixed number of bits treated as a unit can be used to represent a digit, character, or punctuation mark. The relationship with the binary number and the character it represents is arbitrary. Notes: Bit loss indicates that information at the smallest level has changed or become erratic. Within character data, the change of a single bit may be significant; changing the middle bit in A (1000001) to alters it to I (1001001). Such a change in a binary executable file may make it impossible for the program to run or to authenticate a bitstream using a digital signature. However, such a change in an image or sound file may result in only a minor amount of noise. A sequence of binary information transmitted, stored, or received as a unit without regard for internal organization or grouping. In common parlance, the phrase is used to describe any image that fails to capture natural color, although the image may have a distinct, single tone.
Examples include depression symptoms of purchase lexapro cheap online, records of real property; births bipolar depression treatments discount lexapro, marriages great depression test answer key order 20 mg lexapro visa, and deaths (vital records); judicial decisions; minutes of public meetings depression hashtags purchase lexapro 20mg free shipping. Many of these records are held by the office of a city or town clerk, a county recorder, or the secretary of state. The notice imparted by the due and proper record of an instrument, although called a constructive notice, is just as effectual for the protection of the rights of the parties as an actual notice by word of mouth, or otherwise. Commonly used in photographic reproduction, including micrographics, where the original and copy are held together with glass. A contact sheet for 35 mm film typically holds 35 images (seven rows of five images). The shell for the tape in a videocassette may be called a housing, but it is not a container. A container list is distinguished from a folder list, which includes a description of each folder in the container. Notes: Most often refers to the introduction of chemicals or other physical materials, but may also indicate the corruption of a digital or analog signal with noise. A methodology to appraise records by considering the significance of the informational value and the quality of information contained in the records. A contemporary collection of materials about to the Korean War would have a content date in the 20th century and a creation date in the 21st. For example, if Paul Joseph Smith is the authorized name in the authority file, the data content standard might specify that the last name be entered first, as in Smith, Paul Joseph. Many data content standards are guidelines, namely `rules for activities that should be applied as consistently as possible but which, by their nature, will not necessarily produce identical results even when followed. Notes: Continuity ensures that time within a program is perceived as realistic, not the actual time required to make the program. For example, some scenes may be shot several times or be shot in an order different from that in the program. For example, if a scene filmed over a day takes only a few minutes, a clock visible in the scene must appear to represent narrative time, not actual time. The paper is usually intended for use in a computer, and may have holes along the edges to facilitate transport past a print mechanism using a tractor feeder. Notes: Continuous-tone images are distinguished from those made using a line process with one or a few colors of ink. Examples of continuous-tone images include photographic prints, negatives, and transparencies. Low-contrast images have relatively less difference between the highlights and shadows, often lacking a pure white or pure black. Contrast is sometimes expressed as a ratio of the lightest and darkest areas of an image, as measured by a densitometer. Notes: Contributors may supply separate parts of a larger work; for example, several authors may contribute essays to an anthology. A contributor may also serve a specific role for a work as a whole, such as an editor, translator, producer, or director. Common control characters within documents include tab, carriage return, and newline. Other control characters used to control transmission of data include Start of Text, End of Text, and End of Transmission. Control characters used to indicate data records and fields include the file, group, record, and unit separators. The vocabulary may also include crossreferences from nonpreferred terms to preferred terms. It is possible for the same information or records series to be present in two or more units of the University and be the official record copy in each unit if it serves a different function in each of the units.
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