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On physical examination you observe vaginal trauma and scattered bruising and abrasions cheap 10mg levitra visa erectile dysfunction symptoms age. Which of the following medications should be offered to the patient in this scenario? Ceftriaxone order levitra on line amex female erectile dysfunction treatment, azithromycin buy generic levitra on line impotence at age 30, metronidazole, antiretrovirals, emergency contraception b. Ceftriaxone, azithromycin, tetanus, metronidazole, antiretrovirals, emergency contraception Abdominal and Pelvic Pain 101 116. His past medical history includes prostate cancer, left total hip replacement, appendectomy 25 years ago, right iliac artery aneurysm repair 5 years ago, incisional hernia repair 4 years ago, and irritable bowel syndrome. He recalls having similar pain 1 week ago that resolved sponta- neously after 10 minutes. He was recently well and reports no fever, diar- rhea, urinary frequency, or dysuria. Which of the following is an important predisposing factor for the devel- opment of the condition seen in this individual? Provide oxygen via face mask, give morphine sulfate, and order a transvaginal ultrasound. She tells you that she has had this similar presentation four times over the past 2 months. Which of the following extraintestinal manifestations is associated with Crohn disease but not ulcerative colitis? During this time, she has been to the clinic twice, with negative urine cul- tures each time. Her condition has not improved with antibiotic therapy with sulfonamides or quinolones. Which of the following organisms is most likely responsible for the patient’s symptoms? He also describes nausea and vomiting and states he usually drinks 6 pack of beer daily, but has not had a drink for 2 days. Examination shows voluntary guarding and tenderness to palpation of his epigastrium. Admit to the hospital for medical management and supportive care Abdominal and Pelvic Pain Answers 74. The typical patient with mesenteric ischemia may initially present with “pain that is out of proportion to the examination” (ie, although the patient is in pain, the abdomen is neither rigid, nor signif- icantly tender on physical examination). Abdominal distention and peri- toneal signs are late findings and signal the presence of bowel infarction. Although rare, the finding of gas in either the bowel wall (pneumatosis intestinalis) or in the portal venous system is strongly suggestive of intesti- nal infarct. Rotavirus, typ- ically a disease of young children and Norwalk virus are the most frequent etiologic agents. Though dehydration is a common complication, these illnesses are usually self-limited, requiring only supportive care. In the adult, the lower esophageal sphincter is the most common site for impactions. When impaction occurs, patients usually feel some discomfort, sometimes substernal chest pain, anxiety, and progressive dysphagia. Most of the time, 105 106 Emergency Medicine the patient can accurately locate the position of the impacted foreign body. The cricopharyn- geus is the most common site of impaction in children less than 4 years old. The pyloric sphincter (e) is not considered part of the esophagus; rather it helps regulate food passage from the stomach to the duodenum. This can be an area of obstruction as well, as in the case of pyloric stenosis, but is likely to present with characteristic “projectile” vomiting in childhood. This is an acute metabolic acidosis that typically occurs in people who (1) chronically abuse alcohol and have a recent history of binge drinking, (2) have had little or no recent food intake, and (3) have had persistent vomiting. A concomitant metabolic alkalosis is common, secondary to vomiting and volume depletion. The typical symptoms and physical findings relate to volume depletion and chronic alcohol abuse and include nausea, vomit- ing, abdominal pain, and/or hematemesis. Rarely do patients present with muscle pain, fever, diarrhea, syncope, seizure, or melena. Therefore, ketosis may be more severe than would be inferred from a nitroprusside reaction alone. Abdominal and Pelvic Pain Answers 107 As additional treatment, thiamine supplementation should be given as prophylaxis against Wernicke encephalopathy. Because of the poor predictive value of the history, physical and laboratory findings in cholecystitis, the most important test for diagnosis is a strong clinical sus- picion and ultrasound imaging. Ultrasound may show the presence of gallstones as small as 2 mm, gallbladder wall thickening and distention, and pericholecystic fluid. An abdominal aortic aneurysm (d) can present with flank pain, however it is very rare in a 31-year-old man. Testicular tor- sion (e) should always be considered in a patient with groin pain. Sometimes patients have only one or two of the components and occasionally may have none. Trav- eling to Mexico (a) may give you diarrhea and abdominal pain from enteri- tis. Ethanol abuse (b) can lead to abdominal pain because of many causes, such as gastritis. Constipation (e) will not produce the hyperactive bowel sounds as seen in obstruction. Most people remain subclinical, but the presentation ranges from nausea and vomiting to fulminant hepatitis and liver failure. The patient exhibits stigmata of chronic alcohol disease seen by gynecomastia and spider angiomata. Abdominal and Pelvic Pain Answers 109 The management is principally supportive, with correction of any fluid or electrolyte imbalances, paying special attention to blood glucose (ethanol can suppress gluconeogenesis) and magnesium. Suctioning the patient’s stomach with a nasogastric tube (a) is not indi- cated and should not be performed. Unless this is a known needle stick or mucosal exposure, hepatitis immune globulin (c) is not acutely indicated. Viral hepatitis titers (d) can be drawn as an outpatient if suspicious for a viral infection. Causative organisms include gram-negative enterococcus such as E coli and Klebsiella, as well as Streptococcus sp. Therefore, the most appropriate antibiotic for treat- ment is a third-generation cephalosporin, such as cefotaxime.

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Unrealistic goals set the client up for failure and reinforce feelings of powerlessness order cheap levitra online erectile dysfunction treatment philadelphia. Client’s emotional condition interferes with his or her ability to solve problems discount levitra 10 mg without prescription osbon erectile dysfunction pump. Assistance is required to per- ceive the benefits and consequences of available alternatives accurately order levitra amex erectile dysfunction only at night. Help client identify areas of life situation that are not within his or her ability to control. Encourage verbalization of feel- ings related to this inability in an effort to deal with unre- solved issues and accept what cannot be changed. Encourage partici- pation in these activities, and provide positive reinforcement for participation, as well as for achievement. Positive reinforce- ment enhances self-esteem and encourages repetition of desir- able behaviors. Client verbalizes choices made in a plan to maintain control over his or her life situation. Client verbalizes honest feelings about life situations over which he or she has no control. Client is able to verbalize system for problem solving as required for adequate role performance. Possible Etiologies (“related to”) [Withdrawal into the self] [Underdeveloped ego; punitive superego] [Impaired cognition fostering negative perception of self and the environment] Defining Characteristics (“evidenced by”) Inaccurate interpretation of environment [Delusional thinking] Hypovigilance [Altered attention span]—distractibility Egocentricity [Impaired ability to make decisions, problem solve, reason] [Negative ruminations] Goals/Objectives Short-term Goal Client will recognize and verbalize when interpretations of the environment are inaccurate within 1 week. Long-term Goal By time of discharge from treatment, client’s verbalizations will reflect reality-based thinking with no evidence of delusional or distorted ideation. Convey your acceptance of client’s need for the false belief, while letting him or her know that you do not share the delusion. A positive response would convey to the client that you accept the delusion as reality. Use reasonable doubt as a therapeutic technique: “I understand that you believe this is true, but I personally find it hard to accept. Use the techniques of consensual validation and seeking clari- fication when communication reflects alteration in thinking. Use real situations and events to divert client away from long, purposeless, repetitive verbalizations of false ideas. Give positive reinforcement as client is able to differenti- ate between reality-based and non–reality-based thinking. Positive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Teach client to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail. This noise or command distracts the individual from the unde- sirable thinking that often precedes undesirable emotions or behaviors. Clients who are suspicious may perceive touch as threatening and may respond with aggression. Client is able to recognize negative or irrational thoughts and intervene to “stop” their progression. Possible Etiologies (“related to”) Inability to ingest food because of: [Depressed mood] [Loss of appetite] Mood Disorders: Depression ● 141 [Energy level too low to meet own nutritional needs] [Regression to lower level of development] [Ideas of self-destruction] Defining Characteristics (“evidenced by”) Loss of weight Lack of interest in food Pale mucous membranes Poor muscle tone [Amenorrhea] [Poor skin turgor] [Edema of extremities] [Electrolyte imbalances] [Weakness] [Constipation] [Anemias] Goals/Objectives Short-term Goal Client will gain 2 lb per week for the next 3 weeks. Long-term Goal Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e. In collaboration with dietitian, determine number of calories required to provide adequate nutrition and realistic (accord- ing to body structure and height) weight gain. Encourage client to increase fluid consump- tion and physical exercise to promote normal bowel func- tioning. Depressed clients are particularly vulnerable to constipation because of psychomotor retardation. This information is necessary to make an accurate nutritional assessment and maintain client safety. Determine client’s likes and dislikes, and collaborate with dietitian to provide favorite foods. Ensure that client receives small, frequent feedings, includ- ing a bedtime snack, rather than three larger meals. Administer vitamin and mineral supplements and stool softeners or bulk extenders, as ordered by physician. If appropriate, ask family members or significant others to bring in special foods that client particularly enjoys. Stay with client during meals to assist as needed and to offer support and encouragement. Client may have inadequate or inaccurate knowl- edge regarding the contribution of good nutrition to overall wellness. Vital signs, blood pressure, and laboratory serum studies are within normal limits. Possible Etiologies (“related to”) [Depression] [Repressed fears] [Feelings of hopelessness] [Anxiety] [Hallucinations] [Delusional thinking] Defining Characteristics (“evidenced by”) [Verbal complaints of difficulty falling asleep] [Awakening earlier or later than desired] [Interrupted sleep] Verbal complaints of not feeling well rested [Awakening very early in the morning and being unable to go back to sleep] Mood Disorders: Depression ● 143 [Excessive yawning and desire to nap during the day] [Hypersomnia; using sleep as an escape] Goals/Objectives Short-term Goal Client will be able to sleep 4 to 6 hours with the aid of a sleeping medication within 5 days. Long-term Goal Client will be able to fall asleep within 30 minutes of retiring and obtain 6 to 8 hours of uninterrupted sleep each night with- out medication by time of discharge from treatment. Accurate baseline data are important in planning care to assist client with this problem. Administer antidepressant medication at bedtime so client does not become drowsy during the day. Assist with measures that may promote sleep, such as warm, nonstimulating drinks, light snacks, warm baths, back rubs. Administer sedative medications, as ordered, to assist client to achieve sleep until normal sleep pattern is restored. Client is dealing with fears and feelings rather than escaping from them through excessive sleep. Bipolar Disorders Bipolar disorders are characterized by mood swings from pro- found depression to extreme euphoria (mania), with intervening periods of normalcy. It is usually not severe enough to require hospitalization, and it does not include psychotic features. The diagnostic picture for bipolar depression is identical to that described for major depressive disorder, with one exception—the client must have a history of one or more manic episodes. When the symptom presentation includes rapidly alternating moods (sadness, irritability, euphoria) accompanied by symp- toms associated with both depression and mania, the individual is given a diagnosis of bipolar disorder, mixed. Bipolar I Disorder Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of manic or mixed symptoms.

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Although these background factors may influence contraceptive use buy generic levitra 10 mg on line erectile dysfunction treatment without side effects, whether this effect is direct or through the effect of other factors such as knowledge and attitudes is unclear levitra 20 mg lowest price statistics on erectile dysfunction. Intrapersonal factors 1 Knowledge: Whitley and Schofield (1986) analysed the results of 25 studies of contraceptive use and reported a correlation of 0 purchase levitra 20mg visa erectile dysfunction solutions pump. For example, Cvetkovich and Grote (1981) reported that of their sample 10 per cent did not believe that they could become pregnant the first time they had sex, and 52 per cent of men and 37 per cent of women could not identify the periods of highest risk in the menstrual cycle. In addition, Lowe and Radius (1982) reported that 40 per cent of their sample did not know how long sperm remained viable. Negative attitudes included beliefs that ‘it kills spontaneity’, ‘it’s too much trouble to use’ and that there are possible side effects. In addition, carrying contraceptives around is often believed to be associated with being promiscuous (e. This research assumes that certain aspects of individuals are consistent over time and research has reported associations between the following types of personality: s conservatism and sex role have been shown to be negatively related to contraceptive use (e. Interpersonal factors Research highlights a role for characteristics of the following significant others: 1 Partner: facets of the relationship may influence contraception use including duration of relationship, intimacy, type of relationship (e. They included interpersonal and situational factors as a means to place the individual’s cognitions within the context of the relationship and the broader social world. These variables can be applied individually or alternatively incorporated into models. In particular, social cognition models emphasize cognitions about the individual’s social world, particularly their normative beliefs. However, whether asking an individual about the relationship really accesses the interaction between two people is questionable. For example, is the belief that ‘I decided to go on the pill because I had talked it over with my partner’ a statement describing the interaction between two individuals, or is it one individual’s cognitions about that interaction? Although sometimes ignored, this research is also relevant to other sexually transmitted diseases. Since then, health education programmes have changed in their approach to preventing the spread of the virus. For example, early campaigns emphasized monogamy or at least cutting down on the number of sexual partners. Campaigns also promoted non- penetrative sex and suggested alternative ways to enjoy a sexual relationship. As a result, research has examined the prerequisites to safer sex and condom use in an attempt to develop successful health promotion campaigns. Richard and van der Pligt (1991) examined condom use among a group of Dutch teenagers and report that 50 per cent of those with multiple partners were consistent condom users. It reported that 16 per cent of these used condoms on their own, 13 per cent had used condoms while on the pill, 2 per cent had used condoms in combination with spermicide and 3 per cent had used condoms together with a diaphragm. Overall only 30 per cent of their sample had ever used condoms, while 70 per cent had not. Fife-Schaw and Breakwell (1992) undertook an overview of the literature on condom use among young people and found that between 24 per cent and 58 per cent of 16- to 24-year-olds had used a condom during their most recent sexual encounter. In terms of their condom use with their current partner, 25 per cent reported always using a condom with their current male partner, 12 per cent reported always using a condom with their current female partner, 27 per cent reported some- times/never using a condom with their male partner and 38 per cent reported some- times/never using a condom with their female partner. In terms of their non-current partner, 30 per cent had had unprotected sex with a man and 34 per cent had had unprotected sex with a woman. Bisexuals are believed to present a bridge between the homosexual and heterosexual populations and these data suggest that their frequency of condom use is low. They reported that over the one-year follow-up, condom use during vaginal intercourse with prostitutes/clients was high and remained high, condom use with private partners was low and remained low, but that both men and women reduced their number of sexual partners by 50 per cent. The results from the General Household Survey (1993) provided some further insights into changes in condom use in Britain from 1983 to 1991 (see Figure 8. These data indicate an overall increase in condom use as the usual form of contraception, which is particularly apparent in the younger age groups. However, since this time there has been an increase in rectal gonorrhoea and clinical experience, cross-sectional and longitudinal Fig. These data suggest that many individuals do report using condoms, although not always on a regular basis. Therefore, although the health promotion messages may be reaching many individuals, many others are not complying with their recommendations. Predicting condom use Simple models using knowledge only have been used to examine condom use. These models are similar to those used to predict other health-related behaviours, including contraceptive use for pregnancy avoidance, and illustrate varying attempts to understand cognitions in the context of the relationship and the broader social context. Rosenstock 1966; Becker and Rosenstock 1987) (see Chapter 2) and has been used to predict condom use. They reported that the components of the model were not good predictors and only perceived susceptibility was related to condom use. This suggests that condom use is a habitual behaviour and that placing current condom use into the context of time and habits may be the way to assess this behaviour. This presents the problem of a ceiling effect with only small differences in ratings of this variable. Abraham and Sheeran (1993) suggest that social skills may be better predictors of safe sex. These models address the problem of how beliefs are turned into action using the ‘behavioural intentions’ component. In addition, they attempt to address the problem of placing beliefs within a context by an emphasis on social cognitions (the normative beliefs component). In a recent study of condom use, the best predictors appeared to be a combination of normative beliefs involving peers, friends, siblings, previous partners, parents and the general public. This suggests that although cognitions may play a role in predicting condom use, this essentially interactive behaviour is probably best understood within the context of both the relationship and the broader social world, highlighting the important role of social cognitions in the form of normative beliefs. The role of self-efficacy The concept of self-efficacy (Bandura 1977) has been incorporated into many models of behaviour. In terms of condom use, self-efficacy can refer to factors such as confidence in buying condoms, confidence in using condoms or confidence in suggesting that condoms are used. In addition, this model may be particularly relevant to condom use as it emphasizes time and habit. For example, whereas Fisher (1984) reported an association between intentions and actual behaviour, Abraham et al. However, such studies have used very different popula- tions (homosexual, heterosexual, adolescents, adults). Perhaps models of condom use should be constructed to fit the cognitive sets of different populations; attempts to develop one model for everyone may ignore the multitude of different cognitions held by different individuals within different groups.

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But people have been coping with mental health conditions for a long time without modern medicines buy generic levitra 10mg on line erectile dysfunction commercial bob, and many consumers are conversant with and use these remedies purchase levitra with visa erectile dysfunction hypertension medications. Often discount levitra 20mg with amex erectile dysfunction tucson, these systems have evolved apart from and earlier than the conventional medical approach used in the United States. Examples of systems that have developed in non-Western cultures include traditional Chinese medicine and Ayurveda. This outline will not discuss these medical systems but will discuss biologically-based (herbal medicine) practices derived from them which have been studied and found to have an evidence base. People wishing to study or use such medical systems need to consult accomplished practitioners. The sources contain discussions of homeopathy (Mischoulon and Rosenbaum and Lake and Spiegel), Chinese medicine (Lake and Spiegel), acupuncture (Mischoulon and Rosenbaum), and Ayurveda (Lake and Spiegel). This outline will discuss those treatments that have been studied and found to be promising based on the best evidence that we now have. Biologically-Based Practices Biologically-based practices use substances found in nature, such as herbs, foods, and vitamins, as remedies. Some examples include dietary supplements, herbal products, and the use of other natural, but as yet scientifically unproven therapies. These treatments are easily available and extensively used in America, now appearing in your neighborhood grocery. The biologically- based practices that have been found to work in alleviating mental health conditions are the focus of this outline. Energy Medicine Energy therapies (a controversial term little used in the field) involve the use of magnetic and electrical (or electro-magnetic) fields. They are of two types: Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. Some forms of energy therapy manipulate biofields by applying pressure or manipulating the body by placing the hands in, or through, these fields. Lake and Spiegel discuss these therapies, as does Scott Shannon in his Handbook of Complementary and Alternative Therapies in Mental 18 Health. Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, 19 such as pulsed fields, magnetic fields, or alternating-current or direct-current fields. Most importantly, if a person suffering from a serious mental health condition has not responded well to standard treatments or has been unable to tolerate the side effects, it makes sense to consider less well-proven treatments. Further, within each of these professions, individuals and groups use the existing evidence bases in different ways and for different purposes. Sometimes there are studies, of ascending quality as a promising treatment is studied more, but many times there are only preliminary data and clinical experience. In contrast, the physician’s goal is to get the patient/consumer as well as possible. Some consumers are more conservative and require a higher level of proof, while others are more willing to try new options even if there is only a small chance of success so long as the risks are low. The researcher aims to demonstrate significant, reproducible treatment effects that can be defended as valid. The uncounseled consumer is in a more difficult position, without the experience of clinical practice, relying on what the studies have shown. And often the evidence is only promising, based on research rather than anecdote, but open-label, not placebo-controlled, not randomized, with small groups and for short periods. People considering the evidence presented in this outline need to consider all of these shortcomings, but where the risk is truly not significant, a more lenient standard may be appropriate. Progress in genomics has shown that polymorphisms play a significant role in how an individual will or will not respond to treatments. Ultimately, when scientific studies are repeated using genomic measures so that the polymorphisms for each subject are documented, the research probably will show that there is a significant genetic effect on outcomes that will account for the differences in response rates. Then, by selecting people with the most responsive polymorphisms, we will develop studies showing much higher response rates. The Natural Standard always has the longest list of possible drug interactions, often with no notation about the prevalence of the interaction and many warnings of potential interactions and side effects that have not yet been observed in clinical practice. Nonetheless, this outline will report the listed possible interactions and side effects, in truncated form, giving information from the other sources as much as possible to put concerns in perspective. Food and Drug Administration issued a 2003 Final Task Force Report on its “Consumer Health Information for Better Nutrition Initiative,” which proposed that more and better 22 information be made available about dietary supplements. However, the data examined in this outline have yet to be submitted to this process, in part because of cost considerations and in part due to the paucity of well-designed studies and the gaps noted in this outline. In fact, the new Guidance goes so far as to eliminate separate review of “qualified” health care claims based on its conclusion that the standard is essentially the same as for any health care claim. According to Berkeley Wellness, there have been numerous reports of dietary supplements containing much less, or much more, than what’s listed on the labels. Not surprisingly, manufacturers fought against measures that would increase costs. In particular, the provision to test finished products was dropped in the final rule. Ingredients can still have side effects and unknown long-term effects, interact with drugs and be dangerous if you have certain medical conditions. Unlike labels on drugs, those on supplements still need not list any precautions, contraindications or possible interactions -- another reason for this outline. We must never relax our vigilance in reaching out to protect the stigmatized, marginalized people who, abandoned by lack of government funding of both institutional and community-based treatment, roam our streets and sleep under our bridges. But we must do more to help the broader group of people who want to make their lives better and need basic scientific information about alternatives. Development of Balanced Information: It is in the interest of persons with mental health and substance use conditions that research and education be dedicated to investigating and disseminating reliable scientific information concerning behavioral health medications and other treatments, services and supports. All mood stabilizers treat mania and hypomania, and some have been found to be effective in treating depression as well. Other mood stabilizers currently used were originally developed to treat seizure disorders, such as epilepsy, and are thus called anticonvulsants. Acute episodes of mania result in psychosis in as many as two-thirds of those with this disorder. They are also often used to decrease symptoms of mania until mood stabilizers such as those listed above can take full effect. Anti-anxiety drugs in a class called benzodiazepines are sometimes used to gain rapid control of manic symptoms so that mood stabilizers have time to take effect. These medications are primarily used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and prevent seizures. People who regularly focus on the positive in their lives are less upset by painful memories.