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T h e L a n d e s B io s c ie n c e V a d e m e c u m b o o k s a r e in t e n d e d t o b e u s e d b o t h in t h e Date: 2006. S p e c i a l I m a g i n g S t u d i e s E m e r g e n c i e s f o r t h e E m e r g e n c y D e p a r t m e n t : A n g i o g r a p h y M R I V / Q 1 0. I n f e c t i o u s D i s e a s e E m e r g e n c i e s T h e V a d e m e c u m s e r ie s in c l u d e s s u b j e c t s g e n e r a l l y n o t c o v e r e d in o t h e r h a n d b o o k s e r i e s , e s p e c i a l l y m a n y t e c h n o l o g y - d r i v e n t o p i c s t h a t r e f l e c t t h e i n c r e a s i n g in f l u e n c e o f t e c h n o l o g y in c l in ic a l m e d ic in e. T h e n a m e c h o s e n f o r t h is c o m p r e h e n s iv e m e d ic a l h a n d b o o k s e r ie s is V a d e m e c u m , a L a t in w o r d t h a t r o u g h l y m e a n s “ t o c a r r y a l o n g ”. I n t h e M id d l e A g e s , t r a v e l in g c l e r ic s c a r r ie d p o c k e t - s iz e d b o o k s , e x c e r p t s o f t h e c a r e f u l l y t r a n s c r ib e d c a n o n s , k n o w n a s V a d e m e c u m. I n t h e 1 9 t h c e n t u r y a m e d ic a l p u b l is h e r in G e r m a n y , S a m u e l K a r g e r , c a l l e d a s e r ie s o f p o r t a b l e m e d ic a l b o o k s V a d e m e c u m. T h e L a n d e s B io s c ie n c e V a d e m e c u m b o o k s a r e in t e n d e d t o b e u s e d b o t h in t h e t r a in in g o f p h y s ic ia n s a n d t h e c a r e o f p a t ie n t s , b y m e d ic a l s t u d e n t s , m e d ic a l h o u s e s t a f f a n d p r a c t ic in g p h y s ic ia n s. Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. In view of the ongoing research, equipment development, changes in governmental regulations and the rapid accumulation of information relating to the biomedical sciences, the reader is urged to carefully review and evaluate the information provided herein. Greenspan, Calder, Swadron and Brown for their invalu- able aid, and to all the authors, for their efforts on behalf of, and patience with, this project. Henderson Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U. Swadron Department of Emergency Medicine Keck School of Medicine University of Southern California Los Angeles, California, U. Benson Olly Duckett Department of Emergency Medicine Department of Emergency Medicine Keck School of Medicine WakeMed University of Southern California University of North Carolina - Chapel Hill Los Angeles, California, U. Mallon Department of Emergency Medicine Department of Emergency Medicine Lankenau Hospital Keck School of Medicine Wynnewood, Pennsylvania, U. Korn University of Southern California Department of Emergency Medicine Los Angeles, California, U. Keck School of Medicine Chapter 3 University of Southern California Los Angeles, California, U. Richmond Louisiana State University Department of Emergency Medicine and Loma Linda University Medical Center Medical Center of Louisiana and New Orleans, Louisiana, U. Chapter 2 Paul Silka Department of Emergency Medicine Mark Thoma Cedars Sinai Medical Center Department of Emergency Medicine and Davis Medical Center Keck School of Medicine University of California University of Southern California Davis, California, U. Slaven Department of Psychiatry Department of Emergency Medicine University of Rochester Louisiana State University Health Rochester, New York, U. As we progressed it became obvious that the very breadth of the specialty prevented any one person from accomplish- ing this task. It also became obvious that our specialty had advanced past the point where succinctness was possible. Resuscitation, a word derived from the Latin word meaning “to set in motion”, is the term most commonly used to describe the emergent treatment of the most se- verely ill and injured patients. To the emergency physician, the term encompasses not only attempts to reanimate those patients in cardiopulmonary arrest, but the treatment of virtually any diseases in the extremes of presentation. Resuscitation is an active process that is intervention-oriented and often invasive. Resuscitation and the Downward Spiral of Disease Most disease processes move through stages of severity, beginning with an asymp- tomatic phase and progressing toward their end-stage. Generally speaking, distur- bances in one physiologic function lead to disturbances in others and, through a sort of pathologic “multiplier effect”, diseases gain momentum as they progress. Diseases that have reached their end-stage often have such momentum that they require intensive and rapid intervention if there is to be any hope of reversing the underlying pathology. Although patients may present to the emergency department at any stage in the continuum, it is those patients at the bottom of the spiral, those with decompensated and end-stage disease, that will require resuscitation. In general, attempts are made to tailor the treatment of a particular patient to the tempo of their disease. The treatment of these processes should ideally occur at a similar pace, because abrupt changes may cause additional risk to the patient.

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Once the student’s safety is assured generic 30 caps diarex mastercard, they In recognition of the primacy of the educa- should immediately notify people related to tional goals for students enrolled the full- the Clerkship buy diarex 30 caps visa, as appropriate (e. Stu- provide guidance to students, faculty, and dents will generally be required to remediate administrators: any time or activities upon safe return or at a 1. Students must be in good academic stand- tant Deans of Student Affairs to obtain approv- ing in order to be eligible for employment by al for the event. Documentation of this stand- ing will be coordinated by the Offce of Student Financial Aid Affairs. If there is evidence that the student’s academic performance is placing the student Satisfactory Academic at-risk for failing, in addition to the usual sup- ports offered in these situations, the student’s Progress Review employment status will be reviewed by the Federal law and regulations require that all Offce of Student Affairs in collaboration with students receiving federal fnancial assis- the student. This could result in termination of tance must maintain satisfactory academic University employment. The policy applies to all students who Offce of Student Affairs describing the pro- receive federal fnancial aid assistance. This form also requires In determining student’s academic prog- information from the proposed supervisor of ress, the Financial Aid Offce will follow the the employment and an acknowledgement on School of Medicine’s Student Promotion their part of awareness of this policy. Committee academic review policy which is established for all students and meets the 4. Student academic standing and satisfac- However, only six weeks of paid elective credit tory academic progress will be reviewed can count toward the cumulative elective cred- annually by the Financial Aid Offce to deter- it required for graduation. Evaluations will be the Offce of Student Affairs and could result made on both a qualitative and quantitative in disciplinary action or referral to the appropri- basis. Alcohol Policy for Qualitative Review The Financial Aid Offce will follow the rec- Medical Students ommendations of the Committee on Student Promotions for the qualitative review of aca- Intoxication in the workplace is considered demic progress status of the student. Therefore, this The School of Medicine’s Committee on policy shall regulate the use of alcohol at Student Promotions reviews and assesses school sponsored/sanctioned medical stu- the satisfactory academic progress of all dent events on the premises of the Johns medical students at scheduled intervals. Hopkins University School of Medicine and For continued fnancial aid eligibility, the Health System. At events where alcohol is served, the orga- aid funding, will have their fnancial aid status nizers must provide ample non-alcoholic bev- reviewed by the Financial Aid Offce and the erage choices. All events serving alcohol are required to nee to determine continued aid eligibility. Bartenders are The Financial Aid Offce will monitor the expected to deny alcohol to anyone who quantitative time frame for completion of the appears to be impaired from alcohol. It is also the duty ment of program completion, the Financial of students as well as faculty to report dishon- Aid Offce will count all terms and academic est acts to the course director or other faculty years even if the student did not receive fed- member, the Dean, or an Associate Dean. Such acts are dealt calculation for which the student is expected with in the manner prescribed under “Pro- to complete their program. The honor code, developed by the medical Students, who exceed the maximum time student body, introduced in September 1991, frame for completion of their program, will be is as follows: denied any additional fnancial aid funding. As a student at The Johns Hopkins School of Evaluation Periods Medicine, I pledge: The Financial Aid Offce will complete review To do my own work and be honest in my of a student’s academic record at the end of interactions with peers, faculty, and staff. This applies to my work on examinations, The Registrar’s Offce will provide a report assignments, and papers as well as work which will identify those students who may be in the laboratory. To uphold the high standard of conduct The Financial Aid Offce and the Associ- in patient care which has always been ate Dean of Student Affairs or designee, will maintained by the Johns Hopkins medical determine student’s continued eligibility for community. To act on infractions of the honor code, and Involuntary Leave of to maintain the confdentiality of all parties Absence involved. Students may be asked to withdraw or be To encourage my peers to uphold this placed on an involuntary medical leave of honor code. It is the expectation that every student Prior notice and the opportunity to be heard live by this Honor Code. However, the School of Medicine Special Students/ reserves the right to conclude that, on cer- Visiting Students tain occasions, conditions exist which war- rant an immediate leave of absence in order Under special circumstances a limited num- to avert imminent harm to the student, or to ber of properly qualifed persons may be other persons or property. In such an event, admitted as special students to courses a student on an involuntary leave of absence offered by the School of Medicine. Exceptions to this poli- Students may interrupt their course of study cy require the approval of the Vice Dean for to enroll in a combined degree program. Credit will not be given for such Leave of absence status may be requested work toward the M. Moreover, since clerk- or clinical work at Johns Hopkins or another ship opportunities are necessarily limited, the approved site. Students in-residence are School must give frst consideration to place- assessed a minimal registration fee. Enroll- ment of visiting students is usually limited to one nine week period per academic year. Interdivisional Studies Information on application, fees and health insurance requirements may be obtained Regularly matriculated students through- from the Offce of the Registrar on the fol- out the University are eligible to register for lowing website: http://www.

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A third of adolescents with autism develop epilepsy order diarex 30caps with amex, and it is associated with other syndromes such as Tuberose Sclerosis diarex 30caps for sale, Sturge- Weber syndrome and Rett’s syndrome. That is why a thorough full psychiatric and medical history and mental state is required. An informant is essential especially as witness to the seizures and a full description of seizure is required, i. Epilepsy is associated with increased prevalence of nearly all forms of psychiatric disorder. Possible mechanisms include greater social disadvantage, chronic potentially life threatening illness, accidents, head injuries, self-esteem issues, dependency on others. Some studies report that rates of psychosis are higher in those with milder disability and epilepsy, whereas depression rates are higher in those with severe disability. A complex relationship exists between poor impulse control, epilepsy and socio-cultural factors. Interestingly, ‘Forced Normalisation’ is an uncertain phenomenon but relatives/carers frequently report that patient is improved in mental health terms when fit control not so optimal. This can impact on physical health, psychological health and mortality, and in turn also could have an impact on the families and carers of these individuals. Most antiepileptic drugs have agitation or mental illness as an associated side effect, although carbamazepine, lamotrigine and 248 sodium valproate are also used as mood stabilisers. Finally, the treatment of epilepsy may also reduce cognitive ability (both drugs and surgery). They often report feeling isolated and wanting to have friends, though they may not have the skills necessary to form relationships. Frequently, due to the “one shot learning” style of memory, one unpleasant experience may lead to avoidance and a phobic reaction. They classically have repetitive behaviours and routines that they do usually for pleasure or to calm down their anxiety. The difficulty is deciding whether the level of distractibility or restlessness of the person is in keeping with their general level of functioning, or more severe than should be expected. In the later, stimulant medication could be considered in combination with behavioural programmes and bearing in mind the possibility of exacerbation of epilepsy and tics. That type of mood instability is linked to lack of self-awareness and emotional regulation and managed most successfully with psychological support. The most common prominent feature is the degree of sexual activity, which is associate with hypomania but very unusual in agitated depression. It is common that with anxiety and stress at times of crises develops into an acute and transient psychotic episode. This is defined as ‘culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to limit use of, or result in the person being denied access to, ordinary community facilities’. It can be caused by mental illness such as depression or psychotic disorders, or by environmental factors such as lack of sensory stimulation. Lesch-Nyhan syndrome and several neurotransmitters have also been implicated in its aetiology, e. Generally challenging behaviour presents as a communication of the individual’s needs, whether intentionally or unintentionally. That behaviour that has been labeled as challenging may reflect the lack of resources and the label may reflect the needs of the network rather than the individual. The presentation may have physical, psychological or social underpinnings or a combination of the three and these may have an impact on the treatment and management strategies. A thorough process of assessment is necessary to then be able to manage a case successfully. The assessment usually would include several interviews with professionals, carers and relatives. Physical examination and investigations are required and for more complex cases a deep understanding of the social and systemic context the individual lives in can be quite revealing. Some of the common physical and mental disorders associated with challenging behaviours are: Diagnosed physical complaints: -Dental pain -Urinary tract infection -Respiratory infections -Gastritis/gastric ulcer -Constipation Presumptive physical complaints: -Pyrexia with evidence of local infection -Gastro-esophageal reflux -Gastritis -Headache Diagnosed mental disorders: -Anxiety disorders -Depressive disorder -Psychotic disorders -Insomnia -Hyperkinetic disorders -Autistic disorders Presumptive mental disorders and sub-syndromal: -Anxiety and distress 251 -Inattentiveness Functional assessment is an interactive process that allows a better understanding of the environment and the routines of an individual as well as what the triggers or reinforcing factors of a particular behaviour. It essentially looks at the antecedents (what is happening before the behaviour occurs) and the consequences (what happens after the behaviour) of the behaviour in an attempt to determine what its function might be. Its aim is to replace the difficult behaviour with functionally equivalent ones while looking at and changing environmental and social factors that influence the behaviour or maintain it. With regards to treatment of challenging behaviour with pharmacological interventions it should be mentioned that a Cochrane review of antipsychotic medication for treatment of challenging behaviour confirmed that there is not clear support for drug treatment. In clinical practice though, some of the most complex cases of challenging behaviour might benefit to some extent from this type of medication. Capacity to consent is a concept that means decision specific – a person might have capacity for one sort of decision but not another. People who can’t consent deserve to be treated in their best interests and relevant parties should be consulted when assessing capacity to consent e. In controversial cases or where there is disagreement between parties, a Court can be asked to make a ruling. For treatment of mental disorder, the Mental Health Act (2001) could be used for treatment against a patient’s wishes.

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