Location: anterior wall of the proximal duodenum rv asthma humidifier , Classic presentation: burning epigastric pain 13 hours after eating asthmatic bronchitis 49390 , which is relieved by food c asthma symptoms pregnancy . Gross Small «3 ern) asthma when to go to the hospital , solitary ulcers Round or oval shape Sharply demarcated, "punchedout" ulcers Overhanging margins Radiating mucosal folds lV. Risk factors Dietary factors Smoked fish and meats Pickled vegetables Nitrosamines Benzpyrene Decreased intake of fruits and vegetables H. Presentation Often (90%) asymptomatic until late in the course Weight loss and anorexia Epigastric abdominal pain mimicking a peptic ulcer Early satiety Occult bleeding and iron deficiency anemia iv. Diffuse type Diffuse infiltration of stomach by poorly differentiated tumor cells Signetring cells: nucleus is displaced to the periphery by intracellular mucin Linitis plastica: thickened "leather bottle" like stomach viii. Metastasis Virchow (sentinel) node: left supraclavicular lymph node Krukenberg tumor: spread to the ovary ix. Definition: twisting of a segment of bowel on its vascular mesentery, resulting in intestinal obstruction and infarction ii. Often associated with congenital abnormalities such as intestinal malrotation ill. Definition: telescoping of a proximal segment of the bowel into the distal segment ii. Presentation: intestinal obstruction, abdominal pain, and "currantjelly" stools v. Definition: congenital absence of ganglion cells in the rectum and sigmoid Note colon resulting in intestinal obstruction Acquired megacolon may be iii. Presentation caused by Chagas disease Males > females or ulcerative colitis (toxic Delayed passage of meconium megacolon). Synonyms: glutensensitive enteropathy, nontropical sprue Meissner plexus = submucosal 11. Definition: hypersensitivity to gluten (and gliadin), resulting in loss of small ganglia bowel villi and malabsorption iii. Micro Loss of villi Increased intraepitheliallymphocytes · Increased plasma cells in the lamina propria v. Definition: malabsorptive disease of unknown etiology (infection and/or nutritional deficiency) affecting travelers to tropical regions, such as the Caribbean and South America 11. Definition: decreased blood flow and ischemia of the bowel secondary to ath colon receives blood from erosclerosis with thrombosis, thromboembolism, or reduced cardiac output both the superior and inferior from shock mesenteric arteries. Risk factors Constipation and prolonged straining during bowel movements Pregnancy Cirrhosis 111. Complications Thrombosis (painful) Bleeding (streaks of bright red blood on hard stool) c. Pseudomembranous colitis (antibioticassociated colitis) May develop iron deficiency anemia 1. Definition: acute colitis characterized by the formation of inflammatory pseu domembranes in the intestines ii. Often brought on by a course of broadspectrum antibiotics (especially clindamycin and ampicillin) iv. Micro: Superficial colonic necrosis with an overlying pseudomembrane Pseudomembranes are mushroomshaped inflammatory exudates com posed of neutrophils, mucin, fibrin, and necrotic cellular debris Vll. Clinical findings Appendicitis often starts with periumbilical pain that subsequently local izes to the right lower quadrant Nausea, vomiting, and a fever may also be present 111. Micro: neutrophils are present within the mucosa and muscular wall (muscu laris propria) of the appendix vi. Presentation Most are asymptomatic May contain rests of ectopic gastric mucosa and present with intestinal bleeding Note. Definition: acquired outpouching of the bowel wall, characterized by hernia Given that only two layers tion of the mucosa and submucosa through the muscularis propria of the bowel wall are ii. Epidemiology involved, these acquired outpouchings are technically Extremely common in the United States pseudodiverticula. Definition: benign neoplasm of the colonic mucosa that has the potential to 10 years to progress from progress to colonic adenocarcinoma adenoma to carcinoma, 11. Presentation which makes colonoscopy an Commonly asymptomatic effective tool for identifying Occult bleeding and iron deficiency anemia and removing adenomas before they progress to an invasive malignancy. Third most common tumor in terms of incidence and mortality in the United States ii. Risk factors Lowfiber diet Diet low in fruits and vegetables High red meat and animal fat consumption Adenomatous polyps Hereditary polyposis syndromes Lynch syndrome Ulcerative colitis iii. Pattern of spread Lymphatic spread to mesenteric lymph nodes Distant spread to liver, lungs, and bone vi. Achalasia is due to failure of the lower esophageal sphincter to relax with swallowing. Esophageal bleeding can be due to laceration at the gastroesophageal junction produced by severe vomiting (MalloryWeiss syndrome) or esophageal varices that develop secondary to portal hypertension. Gastroesophageal reflux disease is esophageal irritation and inflammation due to reflux of gastric secretions into the esophagus. Squamouscell carcinoma is the most common form in the world and is associated with heavy smoking, heavy alcohol use, achalasia, and PlummerVinson syndrome. Pyloric stenosis is a congenital stenosis of the pylorus due to marked muscular hypertrophy of the pyloric sphincter, resulting in gastric outlet obstruction. Congenital diaphragmatic hernia is a congenital defect in the diaphragm, resulting in herniation of the abdominal organs into the thoracic cavity. Menetrier disease is a form of hypertrophic gastropathy with enlarged rugal folds that can produce decreased acid production, a proteinlosing enteropathy, and increased risk of cancer. ZollingerEllison syndrome is a form of hypertrophic gastropathy with enlarged rugal folds that occurs secondary to gastrin stimulation by a pancreatic gastrinoma. Acute hemorrhagic gastritis is acute inflammation, erosion, and hemorrhage of the gastric mucosa due to a breakdown of the mucosal barrier and acidinduced injury. Gastric stress ulcers are multiple, small, round, superficial ulcers of the stomach and duodenum. Chronic gastritis is a chronic inflammation of the gastric mucosa resulting in eventual atrophy. Chronic gastritis is subdivided into a fundic type, which is related to autoantibodies to parietal cells and/or intrinsic factor, and an antral type, which is related to Helicobader pylori gastritis. Peptic ulcers are ulcers of the distal stomach and proximal duodenum caused by gastric secretions (hydrochloric acid and pepsin) and impaired mucosal defenses. Gastric carcinomas tend to be asymptomatic until late in their course and may show a variety of histologic patterns. Volvulus is twisting of a segment of bowel on its vascular mesentery, resulting in intestinal obstruction and infarction. Intussusception is telescoping of a proximal segment of bowel into the distal segment. Incarcerated hernia is a segment of bowel that becomes imprisoned within a hernia. Hirschsprung disease is a congenital absence of ganglion cells in the rectum and sigmoid colon resulting in intestinal obstruction. Tropical sprue is a malabsorptive disease of unknown etiology affecting travelers to tropical regions, such as the Caribbean and South America. Inflammatory bowel disease includes Crohn disease, ulcerative colitis, and colitis of indeterminate type. Crohn disease has "skip" lesions, has transmural involvement with formation of granulomas, and tends to form fistulas, abscesses, and sinuses. In contrast, ulcerative colitis is confined to the rectum and colon, has inflammation limited to the mucosa and submucosa with crypt abscess, is more likely to have extraintestinal manifestations, and can cause toxic megacolon. Ischemic bowel disease is the result of decreased blood flow and ischemia of the bowel secondary to atherosclerosis with thrombosis, thromboembolism, or reduced cardiac output from shock. Hemorrhoids are tortuous dilated submucosal veins caused by increased venous pressure. Melanosis coli is a black pigmentation of the colon that is common with laxative abuse.
Practice Guideline for the Treatment of Patients With Major Depressive Disorder asthma mask , Third Edition 35 Each of these medications is efficacious asthma quick reference . Patients typi 99) asthma prognosis , and venlafaxine (75–150 mg/day) and duloxetine cally experience minimal weight gain or even weight loss (60 mg/day) showed comparable efficacy in a pair of trials on bupropion (111) asthma treatment ventilator , and for this reason it may be an ap (100). For venlafaxine and perhaps desvenlafaxine, clini propriate antidepressant for patients who are overweight cally significant norepinephrine reuptake inhibition may or obese. Although trazodone is an effective individual study results from the more than 40 relevant antidepressant, relative to placebo (105, 114, 115), in con randomized controlled trials). Results of comparative temporary practice it is much more likely to be used in studies of desvenlafaxine are not known at this time. There are three formulations of bupropion: im because such a specific advantage has not been consis mediate release, sustained release, and extended release. The severity of side effects from antidepressant medica tions in clinical trials has been assessed both through the a. These adverse events are generally dose dependent side effects varies among classes of antidepressant medi and tend to dissipate over the first few weeks of treatment. Anxiety may be minimized by intro tidepressant, an initial strategy is to lower the dose of the ducing the agent at a low dose. A washout period is essential before and after for education about sexual functioning. If the psychiatrist chooses to discontinue tion is determined to be a side effect of the antidepressant a monoamineuptakeblocking antidepressant medication medication, a number of strategies are available, including Copyright 2010, American Psychiatric Association. Potential Treatments for Side Effects of Antidepressant Medications (continued) Antidepressant Associated a Side Effect With Effect Treatment Other (continued) Hepatotoxicity Nefazodone Provide education about and monitor for clinical evidence of hepatic dysfunction. Falls will disappear with time, lowering the dose, discontinuing Selective serotonin reuptake inhibitors, like other antide the antidepressant, or substituting another antidepressant pressive agents, have been associated with an increased such as bupropion (130). Metaanalyses have sexual side effects, and a variety of other medications have also documented an increased risk of falls in patients been used with anecdotal success (135, 136). Neurological effects the implications of this increase in fall risk are compli Selective serotonin reuptake inhibitors can initially exac cated by the decrease in bone density that has been noted erbate both migraine headaches and tension headaches. Systematically reviewing patients’ medi especially those with Parkinson’s disease. Inquir tantly with tamoxifen, the metabolism of tamoxifen to its ing about a history of falls in the past year and assessing for active metabolite is reduced (76–79), resulting in a poten abnormalities in gait and balance can also help in identi tial decrease in its efficacy in preventing breast cancer re fying patients at particular risk for falling (153). Interaction with other drugs was higher for fluoxetine, fluvoxamine, and paroxetine than for sertra f. Discontinuation syndrome and myoclonus, rhabdomyolysis, renal failure, cardiovas Selective serotonin reuptake inhibitors generally should cular shock, and possibly death (157). Drug interactions symptoms typically resolve without specific treatment the potential for drugdrug interactions differs signifi over 1–2 weeks. Selective serotonin reuptake in more protracted discontinuation syndromes, particularly hibitors have variable effects on hepatic microsomal those treated with paroxetine, and may require a slower enzymes and therefore cause both increases and decreases downward titration regimen. Serotonin norepinephrine reuptake inhibitors cautiously in patients with psychotic disorders. For this reason, mir side effects that reflect noradrenergic activity, including tazapine is often given at night and may be chosen for de increased pulse rate, dilated pupils, dry mouth, excessive pressed patients with initial insomnia and weight loss. Mirtazapine increases serum cholesterol levels in induced hypertension may respond to dose reduction. Although several patients treated the absence of a reduction in hypertension, a different an with mirtazapine were observed to have agranulocytosis tidepressant medication may be considered. Alternatively, in early studies, subsequent clinical experience has not con in a patient with wellcontrolled depressive symptoms, it firmed an elevated risk (172). Trazodone can also cause cardiovascular slower downward titration regimen or change to fluoxet side effects, including orthostasis, particularly among el ine. Other antidepressant medications cluding erectile dysfunction in men; in rare instances, pri a. Bupropion apism occurs, which might require surgical correction Bupropion differs from other modern antidepressants by (174, 175). Neurologic side effects with bupropion include head Side effects with nefazodone include dry mouth, nausea, aches, tremors, and seizures (106). However, in patients with insom dosing schedules for the immediaterelease and sustained nia, the sedating properties of nefazodone can be helpful release formulations, and avoiding use of bupropion in pa in improving sleep (177). Bupropion should also dence of treatmentemergent sexual dysfunction (178, not be used in patients who have had anorexia nervosa or 179) with nefazodone and, unlike trazodone, it has not bulimia nervosa because of elevated risk of seizures (170). Drugdrug sertraline, paroxetine, fluoxetine) due to the resulting in interactions can also be problematic as nefazodone in crease in bupropion blood levels. Bupropion has been as hibits hepatic microsomal enzymes and can raise levels of sociated with a low risk of psychotic symptoms, including concurrently administered medications such as certain delusions and hallucinations. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 41 4. Tricyclic antidepressants effects, whereas the secondary amines desipramine and nortriptyline have less antimuscarinic activity (193). Although patients can develop some degree cardiac risk factors and patients older than age 50 years. Tricyclic antidepressants accommodation may be counteracted through the use of act similarly to class Ia antiarrhythmic agents such as qui pilocarpine eye drops. Dry mouth may be counteracted by nidine, disopyramide, and procainamide, which increase advising the patient to use sugarless gum or candy and en the threshold for excitation by depressing fast sodium suring adequate hydration. Constipation can be managed channels, prolong cardiac cell action potentials through by adequate hydration and the use of bulk laxatives. Anti actions on potassium channels, and prolong cardiac re depressant medications with anticholinergic side effects fractoriness through actions on both types of channels should be avoided in patients with cognitive impairment, (183). Sedation often attenuates carry an increased risk of serious cardiac adverse effects, in the first weeks of treatment, and patients experiencing including mortality (186–189). Patients with major depressive number of other cardiovascular side effects, including disorder with insomnia may benefit from sedation when tachycardia (through muscarinic cholinergic blockade and their medication is given as a single dose before bedtime. If there is no medical to determine whether a management plan to minimize or contraindication, patients with symptomatic orthostatic forestall further weight gain is clinically indicated. If the level is nontoxic and myoclonus is not Copyright 2010, American Psychiatric Association. If the myoclonus is problem atic and the blood level is within the recommended range, a. Hypertensive crises the patient may be treated with clonazepam at a dose of A hypertensive crisis can occur when a patient taking an 0. Amoxapine, a dibenzoxazepine confusion and can possibly lead to stroke and death (119). If orthostatic hypotension is prom only with caution and in selected individuals with treatment inent or associated with gait or balance problems, it may resistant symptoms (205, 206). Other zyme inhibition in the gut and firstpass metabolism in the causes of falls include bradycardia, cardiac arrhythmia, a liver. Potentially danger efficacy of this strategy, which can produce dangerous ous interactions, including hypertensive crises and seroto hypotension (210). Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition 43 b. Implementation of pharmacotherapy and is characterized by abdominal pain, diarrhea, flushing, sweating, hyperthermia, lethargy, mental status changes, Improvement with pharmacotherapy can be observed as tremor and myoclonus, rhabdomyolysis, renal failure, car early as the first 1–2 weeks of treatment, and improve diovascular shock, and possibly death. Others achieve improvement within the first in close proximity to other serotonergic agents, such as bus 2–4 weeks (217–220). In shortterm efficacy trials, all anti pirone or antidepressants (157, 204, 211). Possible treatments for this side effect in effects permitting, before changing to a different antide clude adding dietary salt to increase intravascular volume, pressant medication. In some instances, due to factors or use of the mineralocorticoid fludrocortisone. Pa peripheral edema, which may be helped by the use of sup tients who have achieved some improvement during the port stockings. Weight gain tinue taking antidepressant medication for a total of at Weight gain is also commonly seen in patients treated least 4–8 weeks. Although clinical experience is observed with maximally tolerated doses after 4–8 weeks limited, results of one 52week study suggested that treat of treatment, reappraisal and adjustment of the pharmaco ment with transdermal selegiline may not be associated therapy should be considered. The transdermal formu tom response have not been rigorously investigated with lation of selegiline appears to have a relatively low risk of fixeddose studies, and minimum effective doses have not sexual side effects (213). Therefore, the initial aches and insomnia; these side effects may diminish over doses and usual adult doses in Table 6 are intended to time with continued use.
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The percentage of menopausal women increases with age asthma symptoms babies and toddlers , from 1% among those age 3034 to asthma treatment ladder nice 51% among those age 4849 (Table 5 bronchial asthma medical definition . Sample: Women age 2049 and 2549 the age at which childbearing commences is an important determinant of the overall level of fertility as well as the health and wellbeing of the mother and child asthma upper back pain . This means that half of women age 2549 give birth for the first time before age 21 (Table 5. Patterns by background characteristics fi Urban women age 2549 begin childbearing 3. Sample: Women age 1519 Teenage pregnancy is a major health concern because of its association with higher morbidity and mortality for both the mother and the child. Childbearing during adolescence is known to have adverse social consequences, particularly regarding educational attainment, as women who become mothers in their teens are more likely to drop out of school. In Nigeria, 19% of women age 1519 have begun childbearing; 14% have given birth, and 4% are pregnant with their first child (Table 5. Trends: the percentage of teenagers who have given birth or are pregnant with their first child has decreased since 1990, from 28% to 19%. Patterns by background characteristics fi Teenagers in rural areas are three times as likely to have begun childbearing as their urban peers; 27% of rural teenagers have had a live birth or are pregnant, as compared with 8% of urban teenagers (Table 5. The percentage of teenagers who have begun childbearing rises from 1% among those with more than a secondary education to 23% among those with a primary education and 44% among those with no education. The tendency to initiate sexual intercourse before age 15 is higher among women than men (9% versus 2%). Eight percent of women age 1519 were married by age 15, and 1% had given birth by that age. Rates for the 1014 age group are based on retrospective data from women age 1517. For the 04 year period, rates for the 1014 age group are based on retrospective data from women age 1519. Rates for the 1014 age group are based on retrospective data from women age 1519. The interval for multiple births is the number of months since the preceding pregnancy that ended in a live birth. An asterisk indicates that a figure is based on fewer than 25 unweighted cases (smoothed data) and has been suppressed. This information may suggest the direction that fertility patterns will take in the future. This chapter presents information on whether and when married women and men want more children, ideal family size, whether the last birth was wanted, and the theoretical fertility rate if all unwanted births were prevented. Sample: Currently married women and men age 1549 Sixtyseven percent of currently married women age 1549 want to have another child; 34% of these women want to have another child within 2 years, 30% want to wait at least 2 years, and 4% are undecided on when they would want another child. The majority of other women want to limit childbearing: 24% of currently married women want no more children or are sterilised. Overall, 77% of currently married men age 1549 want to have another child; 44% want the child within 2 years, 29% want to wait at least 2 years, and 4% are undecided with respect to time. Nineteen percent of currently married men want no more children or are sterilised (Table 6. Fertility Preferences 117 Trends: With respect to number of living children, ure 6. Patterns by background characteristics 4 children33 fi the more children a woman already has, the 26 27 more likely she is to want no more children. For example, among women who have four children, 20% of 51 43 those with no education want no more children, 33 as compared with 49% of those with more than a 18 secondary education. The ideal family size is slightly larger among women and men age 1549 women and men who are currently married ure Women Men 6. Patterns by background characteristics All Currently married fi In general, the more children respondents already have, the more children they consider ure 6. On the other Mean ideal number of children hand, women with six or more children consider Women Men 8. Sample: Current pregnancies and births in the 5 years before the survey to women age 1549 Fertility Preferences 119 Most births were wanted at the time of conception ure 6. Only 3% of births were not wanted at all age 1549 in the 5 years before the survey (Table 6. Similarly, there have Mistimed been only minimal changes in the percentages of 8% unwanted births (2% in 2013 and 3% in 2018) and Wanted then mistimed births (7% in 2013 and 8% in 2018). One percent of births to women less than age 25 were unwanted, compared with 12% of births to women age 4549 (Table 6. Wanted birth Any birth fewer than or equal to the number of children a woman reported as her ideal number. Wanted fertility rate the average number of children a woman would have by the end of her childbearing years if she bore children at the current age specific fertility rates, excluding unwanted births. Sample: Women age 1549 the wanted fertility rate measures the potential demographic impact of fertility that would have prevailed in the 3 years preceding the survey if all unwanted births were prevented. It is calculated in the same manner as the total fertility rate, except that only wanted births are included. A birth is considered wanted if the number of living children at the time of conception is fewer than the ideal number of children reported by the respondent. The Wanted and actual number of children wanted fertility rate has decreased to 4. The contraceptive prevalence rate for any method is 17% among currently married women. The most common reason for discontinuation was the desire to become pregnant (35%). This chapter presents information on the use and sources of contraceptive methods, informed choice of Cmethods, and rates and reasons for discontinuing contraceptives. It also examines the potential demand for family planning and how much contact nonusers have with family planning providers. The most commonly known modern methods among currently married women are injectables (88%) and pills (87%), followed by implants (78%), male condoms (77%), and lactational amenorrhoea (58%). Seventytwo percent of currently married women are aware of a traditional method of contraception. Contraceptive prevalence rate Percentage of women who use any contraceptive method. Most currently married women using contraception use a modern method (12%), while 5% use a traditional method. Thirtyseven percent of sexually active unmarried women use a contraceptive method, with 28% using a modern method and 9% using a traditional method (Table 7. The most commonly used modern methods of contraception among currently married women are injectables and implants (3% each), while the most common modern method used by sexually active unmarried women is the male condom (19%) ure 7. Trends: Contraceptive use among currently married women increased from 15% in 2013 to 17% in 2018. Use of any modern method of contraception also increased, from 10% to 12% ure 7. In addition, there has been a noticeable rise in the use of implants since 2008, from 0% to 3% (Table 7. Thirty percent of women using the rhythm method correctly perceive the fertile period to be halfway between two menstrual periods (Table 7. With the exception of women age 1519, approximately one quarter of women in each age bracket correctly identified the fertile period (Table 7. Sample: Women age 1549 currently using a modern contraceptive method In Nigeria, the public sector plays a more prominent ure 7. The private sector is Private the main source for male condoms (81%), medical sector emergency contraception (80%), and pills (67%) 41% (Table 7. Among users of social marketing branded pills, the most common brands are Duofem Confidence (23%) and Combination 3 (21%). Among users of social marketing branded condoms, Gold Circle is the most common brand (66%) and Rough Rider is the least common (7%) (Table 7. Sample: Women age 1549 who are currently using selected modern contraceptive methods and who started the last episode of use within the 5 years before the survey Three quarters (74%) of all women currently using modern contraceptive methods were informed about side effects associated with the method they used, and 68% were informed about what to do if they experienced side effects. Overall, 65% of women currently using modern contraceptives were informed about the method information index (side effects of the method, what to do if they experience side effects, and other available methods) at the time they started their last episode of use (Table 7. Women who initially obtained their method in a family planning clinic were most likely to be informed of the method information index (82%) (Table 7. Sample: Episodes of contraceptive use in the 5 years before the survey experienced by women who are currently age 1549 (one woman may contribute more than one episode) the overall 12month contraceptive discontinuation ure 7.