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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

More than 90% of the cases in military personnel are due to anxiety symptoms in 12 year old boy buy cheap imipramine 50 mg faulty foot mechanics and increased activity demands anxiety feels like order discount imipramine. Subjective: Symptoms Insidious onset of heel pain anxiety 2016 buy discount imipramine on-line, most severe in the morning or when standing up; may acutely follow an injury; pain can be bilateral anxiety girl meme imipramine 75mg low cost. Objective: Signs Using Basis Tools: Point tenderness over medial tubercle of the calcaneus at the level of the plantar fascial attachment, which may radiate distally causing pain and swelling in the arch; more common in pronated foot type but heel pain can present in a high-arch foot type; distant symptoms due to compensatory gait changes; tight Achilles tendon. Using Advanced Tools: X-rays: Spur presents 60% of the time; fracture, bone cyst or arthritic changes may be noted to explain symptoms. Assessment: Differential Diagnosis Bursitis palpate tenderness (inflamed bursa) directly below the calcaneal tubercle. Nerve entrapment point tenderness over nerve; pain radiating into heel; positive Tinel’s sign*. Tarsal tunnel syndrome compression of the posterior tibial nerve; positive Tinel’s sign*. Stress fracture diagnose on x-ray; not common in calcaneous Foreign body usually an entrance portal visible Arthritis (Reiter’s, psoriatic, ankylosing spondylitis, rheumatoid) See Symptom: Joint Pain section. Conservative: Ice (not heat) massage, Achilles stretching, heel pad (foreign body, bursitis, arthritides). Ice massage: Use ice directly on heel and arch but limit to 8-10 minutes 4-6 x day; use Dixie cup technique or frozen plastic water bottle or gel pack if available. Achilles tendon stretching: Any limitation in ankle dorsiflexion increases force on plantar fascia. Anti-inflammatories: Motrin 800 mg po tid with food; arthritides may need steroid injection. Cortisone injection for acute pain: Injection mixture: 1/2 cc long acting steroid i. Consider a Marcaine block to the posterior tibial nerve if previous training and experience. For dive ops, use boot with fin if operational mission involves movement overland once exiting water. Prescription orthotics may be best measure when obvious faulty foot mechanics present. Follow-up Actions Return evaluation: Follow-up 1week or check more regularly if teammate. If conservative measures fail to give any significant relief, consult podiatry or orthopedics. This condition is painful and often results in an infection once the skin is broken, with the offending nail corner acting like a foreign body introducing pathogens. An ingrown nail may result from improper trimming of nails, injury, tight shoes, genetic predisposition and fungal nail infections. Subjective: Symptoms Toe pain, especially in shoes; history of recurrent ingrown nails and infections, and previous procedures to remove the nail. Objective: Signs Using Basic Tools: Most commonly involves great toe; soft tissue penetration and secondary infection, with purulence, tenderness, erythema and edema; excessive granulation tissue in more chronic cases; malodorous wound when gram-negative bacteria involved. Using Advanced Tools: C&S in a severe infection before beginning empiric coverage. X-rays are rarely considered but one should be aware that osteomyelitis secondary to a chronic ingrown nail infection is a possibility if the condition has been neglected or chronic. X-rays will also reveal a subungual exostosis (bony growth under the toenail) when present. Assessment: Diagnose this problem clinically in the field Differential Diagnosis (may be secondary diagnosis) Subungual exostosis spur on the distal phalanx which pushes upward causing the nail to incurvate. Fungal nail infection, subungual hematoma, foreign body reaction (granuloma) Plan: Treatment Primary: Partial nail avulsion 1. Use curette to remove infected necrotic tissue or excessive granulation tissue (proud flesh) from the nail groove. Antibiotics for 7 days: Dicloxacillin 500mg po qid or Keflex 500mg po qid for broader coverage. Patient Education General: Instructions on soaking: add few ounces of Betadine solution to water; remove loose necrotic tissue or scab covering with washcloth while soaking to promote drainage when infected and speed the healing process. No Improvement/Deterioration: If recurrent problem, return for definitive procedure. Follow-up Actions Return evaluation: At 3-5 days, check for any remaining nail spicules (small, needle-shaped pieces); check cultures; consider X-ray. Partial nail avulsion should be considered in recurrent cases once the infection is resolved. A plantar wart can be found as a single lesion or grouped together (referred to as a mosaic wart). Most common areas include the ball of the foot and heel, where increased pressure and irritation is common. These dots are often black (dried blood) due to irritation, when located on the plantar aspect of the foot. Subjective: Symptoms Pain, especially if wart is on prominent plantar area; may have tried over-the-counter preparations, other family or team members may have warts as well. Objective: Signs Using Basic Tools: Lesions tender to palpation and squeezing especially if located on weight-bearing area; callus may form over the wart, increasing pain. Pre-cut felt pads are available, but if material is in sheets, cut and size to fit. Surgical curettage should be reserved for unresponsive cases and is not recommended in the field. Curettage reduces the chance of plantar scarring since the procedure does not involve penetration below the dermis when done correctly. A surgical excision of a wart using two semi-elliptical incisions is a consideration for a wart in a non-weight bearing area. Surgical excision should never be performed on weight bearing areas because of the risk of scarring and subsequent pain with ambulation. Prevention and Hygiene: Use deck shoes or sandals in shower/pool areas to prevent spread among troops. Follow-up Actions Return evaluation: Follow up weekly until resolved Evacuation/Consultation Criteria: Evacuation not normally necessary. Often there is no bump, but rather an angulation of the first metatarsal (hallux abductor valgus) that makes the head of this bone more prominent. Genetic factors, foot mechanics and poorly fitting or excessively worn shoes are commonly blamed for the development of both deformities. Pain is a result of cartilage erosion, bursitis and neuritis in the effected joints. Subjective: Symptoms Pain near first metatarsal head, history of a progressive deformity over time. Objective: Signs Using Basic Tools: Bump, erythema and tenderness medially (tibial aspect) over the first metatarsal head; joint stiffness in more chronic cases, especially with excessive pronation (flat feet). Using Advanced Tools: X-rays are helpful in evaluating angular relationships and joint integrity when available, but are not required. Assessment: Diagnose by clinical presentation/appearance Differential Diagnosis rigid toe due to traumatic osteoarthritis (hallux rigidus or limitus). Local toe irritation (shoe irritation in absence of defor mity) Plan: Treatment: Primary: 1. A doughnut hole cut in felt or several layers of moleskin will work as a substitute for a bunion pad. Multiple injections could weaken joint structures, causing progression of the deformity. Shoe or boot pressure can irritate the cutaneous nerve running medially along the first metatarsal head, causing severe neuritis pain and making ambulation difficult. Patient Education General: Although these are structural deformities, changing shoe style and size may provide the most relief in an operational setting when surgery is not an option. Medications: Motrin 800mg po tid with meals Prevention and Hygiene: Avoid tight shoes. Follow-up Actions Return Evaluation: 1-2 weeks Evacuation/Consultation Criteria: Evacuation is not usually necessary. If no change with conservative measures, refer to podiatrist or orthopedic surgeon. If deformity and symptoms are severe and conservative measures fail, elective surgery is an option.

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Arch sex: impact on depression and commitment in cou Gen Psychiatry 1996; 53:913–919 [A] ples seeking marital therapy anxiety 2 days before menses order imipramine. Practice Guideline for the Treatment of Patients With Major Depressive Disorder anxiety symptoms 4dpiui buy imipramine 75 mg cheap, Third Edition 151 1132 anxiety panic attack symptoms order imipramine on line. Burnand Y anxiety symptoms in young adults buy generic imipramine 75mg, Andreoli A, Kolatte E, Venturini A, ioral marital therapy: empirical status of behavioral Rosset N: Psychodynamic psychotherapy and clo techniques in preventing and alleviating marital mipramine in the treatment of major depression. J Consult Clin Psychol 1988; 56:440–447 Psychiatr Serv 2002; 53:585–590 [A ] [F] 1149. De Jonghe F, Kool S, Van Aalst G, Dekker J, Peen Psychiatry 1990; 147:183–186 [A] J: Combining psychotherapy and antidepressants in 1139. J Affect Disord 2001; skas D, Chevron E: Individual versus conjoint in 64:217–229 [A ] terpersonal psychotherapy for depressed patients 1151. Int J Fam Psychiatry 1989; B: Efficacy of combined therapy and pharmacother 10:29–42 [A ] apy for depressed patients with or without person 1140. De Jonghe F, Hendricksen M, Van Aalst G, Kool S, ing treatment and group psychoeducation for de Peen V, Van R, van den Eijnden E, Dekker J: Psy pression: multicentre randomised controlled trial. Arch Gen Psychiatry 2007; psychometric approach to evaluate clinical effects 64:886–892 [C] of four fixed citalopram doses compared to placebo 1143. Psychopharma of group psychotherapy for depression: a meta cology (Berl) 2002; 163:20–25 [A] analysis and review of the empirical research. Convuls Ther 1994; 10:189–194 [B] fluoxetine and desipramine for rapid treatment 1164. If an individual meets the above criteria for major What makes it difficult to evaluate is the wide range of depression for 2 years or more the condition is called findings associated with the condition and the significant chronic depression. Minor depression is characterised by number of comorbid factors that come into play in the presence of the core symptoms but only 3 or fewer of assessing the mortality risk associated with it. Epidemiology of depression Underwriters really need to understand and synthesise all of the key elements contributing to outcomes and develop a the median age of onset for major depression is in the composite picture for each individual to adequately assess early 30’s. The the spectrum of depression condition is more common in the setting of physical illness, reaching levels of 15%-20% in nursing home residents Depression represents a spectrum from dysthymia to major and 22%-33% in individuals with chronic medical depression. The recurrence rate Evaluating the severity of depression is 50% after a single episode. Risk A number of rating scales have been developed for factors for recurrence include: assessing the severity of depression. It tends to aggregate in families with the risk 3-4 times higher Severe 19-22 > 29 31-38 > 69 in first degree relatives with the disorder. Very > 22 > 38 Stressful life events, such as divorce, death of a loved one Severe or abuse, especially if they occur in childhood, are strong > 23 precipitants. The presence of substance abuse, other medical conditions and some medications such as beta blockers are associated with development of the condition. However, these scores are rarely seen in the underwriting Finally, certain personality traits are associated with major process. This score is intended for use with all mental illnesses and is not specific to depression. It allows an assessment of the overall functioning of the individual based on the type of information that can be easily found in Stressful life events, such as divorce, an underwriting file. It is also 71-80 Symptoms are transient, slight impairment of defined by the presence of at least 2 of the following function symptoms: 61-70 Mild symptoms, some difficulty, generally • Poor appetite or overeating functions well • Insomnia or hypersomnia • Low energy or fatigue 51-60 Moderate symptoms or moderate difficulty in • Low self-esteem functioning • Poor concentration with difficulty with making 41-50 Serious symptoms or serious difficulty in decisions functioning • Feelings of hopelessness 31-40 Impaired reality testing or communication or the symptoms cannot be due to another medical or seriously impaired functioning psychiatric disease and must cause significant impairment of daily functioning. About 70% of dysthymic patients will 21-30 Behavior considerably influenced by psychotic eventually go on to at least one episode of major depression. Both Mild Moderate 61-70 psychotherapy, especially cognitive-behavioral therapy, and medication have been shown to be efficacious. The Moderate 51-60 combination of both of these forms of treatment is better Moderate Severe 41-50 than either used alone. Their low side effect profile and amplify or augment the effects of the established tolerance by patients has allowed primary care physicians antidepressants. These treatments include: lithium, thyroid to now assume the bulk of the care of depressed individuals. For mild to moderate depression there is generally no particular advantage to one drug over another for the Another option for severe or resistant disease is use of non treatment of the depression itself. The most commonly medications is based more on the side effect profile and the used of these is electroconvulsive therapy. For example, has been used for a number of years and is effective in in a person with a significant problem with insomnia, the 50%-70% of cases. It tends to be less effective in bipolar choice of a medicine with sedating effects would be better disorder, minor disease and depression of long duration. The tricyclic drugs may Other, less commonly encountered, but, nevertheless, work somewhat better for severe depression. Red flags with depression A response to medical therapy takes at least 2-3 weeks and may take up to 6-8 weeks or more. The duration of therapy Red flags that would indicate more severe depression or a should be at least 6-12 months after remission is achieved, higher risk situation would include: ideally at the higher end of that range. Long-term maintenance therapy is recommended in certain situations • A prior suicide attempt such as when there has been two episodes with the • Suicidal ideation, especially if there is intent and a presence of risk factors for recurrence and in the presence clear plan of three episodes or more. Thus, cessation of treatment is • Psychotic depression with the presence of delusions or not necessarily a good thing in all cases. Common • Worsening symptoms with the initiation of anti reasons for this include failure to use a high enough dosage, depressant therapy (an indicator of possible bipolar failure to stay on the medication for a long enough period disorder) of time, skipping doses, intolerance of side effects and the • A concomitant severe anxiety disorder presence of accompanying medical, psychiatric and • Non-compliance with treatment substance abuse disorders. Medical conditions can lead to depression and depression can influence the outcome with medical conditions. The presence of other mental illnesses, substance abuse and anxiety can significantly affect the prognosis. Finally, the age, sex and health habits of the individuals involved also come into play in the analysis. In looking more closely at the recent data on the mortality outcomes with depression several things seem clear. First, there appears to be a consistent increase in mortality in Older individuals are more likely to complete suicide if attempted multiple clinical studies (Figure 1). Second, multiple papers show that the mortality is increased in the elderly (Figure 2). Figure 2: Mortality with depression in the elderly Figure 1: Mortality risk with depression Relative risk of mortality by various studies – multivariate Multiple studies – relative risk adjusted Hannover Re | 5 Third, the death rates increase as the severity of depression Finally, relative risk in minor depression is increased but at increases (Figure 3). The increase in years of potential life lost is seen in all categories of psychiatric and medical illness when depressed individuals are compared to those who are not depressed (Figure 4). Surprisingly, the risk is variable and not consistently substantially elevated in association with psychotic depression. Comorbid anxiety, substance abuse and personality disorders are clearly adverse prognostic indicators. The chances of suicide are increased, sooner after the diagnosis of depression, earlier in the lifetime course of the illness, during the first few months after the initiation of therapy, earlier in the course of hospitalisation and in the first month or two after discharge from inpatient care. Everyone occasionally feels blue or sad, but these feelings are usually feeting and pass within a couple of days. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. Depression is a common but serious illness, and most who experience it need treatment to get better. But the vast majority, even those with the most severe depression, can get better with treatment. Intensive research into the illness has resulted in the development of medications, psychotherapies, and other methods to treat people with this disabling disorder. Major depressive disorder, also called major depression, Bipolar disorder, also is characterized by a combination of symptoms that inter called manic-depressive fere with a person’s ability to work, sleep, study, eat, and illness, is not as common enjoy once-pleasurable activities. Major depression is dis as major depression abling and prevents a person from functioning normally. Bipolar An episode of major depression may occur only once in disorder is character a person’s lifetime, but more ofen, it recurs throughout a ized by cycling mood person’s life. More in symptoms that may not disable a person but can prevent formation about bipolar one from functioning normally or feeling well.

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Hamate Fracture There are no specific discussions in the literature concerning hamate fractures in the pediatric population anxiety symptoms 4-6 purchase imipramine 25 mg online. Ulnar and median neuropathy can also be seen anxiety meme cheap 25mg imipramine amex, as well as rare injuries to anxiety symptoms in teens cheap imipramine 75mg visa the ulnar artery anxiety drugs discount imipramine express. Fracture of the hamate is best visualized on the carpal tunnel or 20-degree supina tion oblique view (oblique projection of the wrist in radial devia tion and semisupination). A hamate fracture should not be confused with an os hamulus proprium, which represents a sec ondary ossification center. The injuries are typically crush injuries in toddlers and are typically related to sports participation in adolescents. Conversely, the exuberant periosteum may become interposed in the fracture site, thus preventing effec tive closed reduction. Simple observation of the child at play may provide useful information concerning the location and severity of injury. This should include Patient age Hand dominance Refusal to use the injured extremity the exact nature of the injury: crush, direct trauma, twist, tear, laceration, etc. The exact time of the injury (for open fractures) Exposure to contamination: barnyard, brackish water, animal/ human bite Treatment provided: cleansing, antiseptic, bandage, tourniquet Physical examination: the entire hand should be exposed and exam ined for open injuries. Swelling as well as the presence of gross deformity (rotational or angular) should be noted. If the child is uncooperative and nerve injury is suspected, the “wrinkle test” may be performed. This is accomplished by immersion of the affected digit in warm, sterile water for 5 minutes and observing corrugation of the distal volar pad (absent in the denervated digit). Observing tenodesis with passive wrist motion is helpful for assessing digital alignment and cascade. Injured digits should be viewed individually, when possible, to minimize overlap of other digits over the area of interest. Treatment General Principles “Fight-bite”injuries: Any short, curved laceration overlying a joint in the hand, particularly the metacarpal–phalangeal joint, must be suspected of having been caused by a tooth. These injuries must be assum ed to be contam inated with oral flora and should be addressed with broad-spectrum antibiotics. Hematoma blocks or fracture manipulation without anesthesia should be avoided in younger children. With conscientious follow-up and cast changes as indicated, immobilization is rarely necessary beyond 4 weeks. A higher incidence of late nail deformities associ ated with failure to decompress subungual hematomas has been reported. Stable fracture reductions may be splinted in the “protected po sition, ” consisting of metacarpophalangeal flexion 70 degrees and interphalangeal joint extension to minimize joint stiffness. Percutaneous pinning may be necessary to obtain stable reduc tion; if possible, the metaphyseal component (Thurston Holland fragment) should be included in the fixation. Type B: Metacarpal Neck Fractures of the fourth and fifth metacarpal necks are commonly seen as pediatric analogs to boxer’s fractures in adults. More than 40 to 45-degree angulation for the fourth and fifth metacarpals is unacceptable. Type C: Metacarpal Shaft Most of these fractures may be reduced by closed means and splinted in the protected position. Open reduction is rarely indicated, although the child presenting with multiple, adjacent, displaced metacarpal fractures may require reduction by open means. Type D: Metacarpal Base the carpometacarpal joint is protected from frequent injury owing to its proximal location in the hand and the stability afforded by the bony congruence and soft tissue restraints. Open reduction may be necessary, especially in cases of multiple fracture-dislocations at the carpometacarpal level. Thumb Metacarpal Fractures are uncommon and are typically related to direct trauma. They are treated with closed reduction with extension applied to the metacarpal head and direct pressure on the apex of the frac ture, then immobilized in a thumb spica splint or cast for 4 to 6 weeks. Unstable fractures may require percutaneous Kirschner wire fix ation, often with smooth pins to cross the physis. Closed reduction followed by thumb spica splinting is initially indicated, with close serial follow-up. With maintenance of reduction, immobilization should be continued for 4 to 6 weeks. Percutaneous pinning is indicated for unstable fractures with capture of the metaphyseal fragment if possible. Chapter 46 Pediatric Wrist and Hand 675 They are rare, with deforming forces similar to type B fractures, with the addition of lateral subluxation at the level of the car pometacarpal articulation caused by the intraarticular compo nent of the fracture. The most consistent results are obtained with open reduction and percu taneous pinning or internal fixation in older children. Severe comminution or soft tissue injury may be initially addressed with oblique skeletal traction. External fixation may be used for contaminated open fractures with potential bone loss. Proximal and Middle Phalanges Pediatric fractures of the proximal and middle phalanges are subclassi fied as follows: Type A: physeal Of pediatric hand fractures, 41% involve the physis. The proxi mal phalanx is the most frequently injured bone in the pediatric population. The collateral ligaments insert onto the epiphysis of the proxi mal phalanx; in addition to the relatively unprotected position of the physis at this level, this contributes to the high incidence of physeal injuries. Treatment is initially by closed reduction and splinting in the protected position. Chapter 46 Pediatric Wrist and Hand 677 Proximal phalangeal shaft fractures are typically associated with apex volar angulation and displacement, created by forces of the distally inserting central slip and lateral bands coursing dorsal to the apex of rotation, as well as the action of the intrinsics on the proximal fragment pulling it into flexion. Oblique fractures may be associated with shortening and rota tional displacement. Closed reduction with immobilization in the protected position for 3 to 4 weeks is indicated for the majority of these fractures. Residual angulation 30 degrees in children 10 years of age, 20 degrees in children 10 years of age, or any malrotation requires operative intervention, consisting of closed reduc tion and percutaneous crossed pinning. Rotational displacement and angulation of the distal fragment are common, because the collateral ligaments typically remain attached distal to the fracture site. Closed reduction followed by splinting in the protected position for 3 to 4 weeks may be attempted initially, although closed re duction with percutaneous crossed pinning is usually required. These fractures are difficult to reduce and control by closed means because of the forces imparted by the volar plate and ligaments. Open reduction and internal fixation are usually required for anatomic restoration of the articular surface. This operation is most often performed through a lateral or dorsal incision, with fixation using Kirschner wires or miniscrews. Distal Phalanx these injuries are frequently associated with soft tissue or nail compromise and may require subungual hematoma evacuation, soft tissue reconstructive procedures, or nailbed repair. Alternatively, a mallet finger may result from a purely tendinous disruption and may there fore not be radiographically apparent. Treatment of type A and nondisplaced or minimally displaced type B injuries is full-time extension splinting for 4 to 6 weeks. Type C, D, and displaced type B injuries typically require opera tive management. Treatment is typically closed reduction and splinting for 3 to 4 weeks with attention to concomitant injuries. Unstable injuries may require percutaneous pinning, either longitudinally from the distal margin of the distal phalanx or across the distal interphalangeal joint (uncommon) for extremely unstable or comminuted fractures. Complications Impaired nail growth: Failure to repair the nailbed adequately may result in germinal matrix disturbance that causes anomalous nail growth. This is frequently a cosmetic problem, but it may be addressed with reconstructive procedures if pain, infection, or hygiene is an issue. This occurs most commonly at the level of the proximal interphalangeal joint secondary to tendon adherence.

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