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By S. Zakosh. Muhlenberg College.

Assessment: A normal sacroiliac joint will be resilient: palpating pres- sure will slightly increase the distance between the posterior margin of the ilium and the sacrum citalopram 20 mg medicine quotes. A relatively long range of motion with a hard endpoint suggests hypermobility in the sacroiliac joint purchase citalopram 10mg fast delivery symptoms heart attack. Pain during the examination can occur in both a motion-restricted and a strained hyper- mobile joint (painful hypermobility). Patrick Test (Fabere Sign) Differentiates hip disorders from disorders of the sacroiliac joints (as- sessment of adductor tension). Procedure: The patient is supine with one leg extended and the other flexed at the knee. The lateral malleolus of the flexed leg lies across the other leg superior to the patella. The test may also be performed so that the foot of the flexed leg is in contact with the medial aspect of the knee of the contralateral leg. The examiner must immobilize the pelvis on the extended contralateral side to prevent it from moving during the test. Assessment: Normally the knee of the abducted leg will almost touch the examining table. Comparative measurements of the distance be- tween the knee and the table on both sides are made. On the side of the positive hyperabduction sign, motion is restricted, the adductors are tensed, and the patient feels pain when the leg is further abducted past the starting position of limited abduction. Apart from assessing the tension in the adductors, is should also be considered whether the shortening of the adductors is attributable to hip pain (a soft endpoint) or sacroiliac motion restriction (differential diagnosis). A simple restriction of movement in the hip (hard endpoint) or a intervertebral dysfunction in the lumbar spine can also produce a positive fabere sign. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. By moving the immobilizing hand up the spine, the examiner also evaluate higher segments of the lumbar spine. Assessment: Under normal conditions no pain should occur in any phase of the test. Thesacroiliacjointshouldexhibitslightplay,andthelumbarspineshould allow elastic hyperextension (lordosis) at the lumbosacral junction. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. Pain when the sacrum is immobilized suggests motion restriction of the sacroiliac joint or other disorders of this joint, such as ankylosing spondylitis, while pain when the lumbar spine is immobilized suggests a disorder of the lum- bosacral junction (vertebral motion restriction or protrusion or extru- sion of an intervertebral disk). Note: The test for a Mennell sign is identical to the second phase of the three-phase hyperextension test. Procedure: The examiner stands behind the standing patient and palpates the posterior superior iliac spine and the median sacral crest (spinous processes of the fused sacral vertebrae) at the same level. The patient is asked to raise the ipsilateral leg and push his or her knee as far forward as possible. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. This downward shift will not occur if the sacroiliac joint is motion-restricted; in fact, the motion restriction will usually cause the posterior superior iliac spine to move upwards (superiorly) as the pelvis tilts in compensation. Buckup, Clinical Tests for the Musculoskeletal System © 2004 Thieme All rights reserved. The patient is asked to slowly bend over while keeping both feet in contact with the floor and the knees extended. Assessment: The sacrum rotates relative to the ilia around a horizontal axis in the sacroiliac joints. If nutation does not occur in the sacroiliac joint on one side, the posterior superior iliac spine on that side will come to rest farther superior with respect to the sacrum than the spine on the contralateral side. Where nutation fails to occur or this relative superior advancement is observed, this is usually a sign of a blockade in the ipsilateral sacroiliac joint.

After intraabdominal entry purchase citalopram 10mg on line treatment jokes, ask the patient to elevate herself on elbows to permit grav- ity drainage into the area of needle entry order 20 mg citalopram free shipping 7mm kidney stone treatment. Slow rotation of the needle followed by slow removal may enable a pocket of fluid to be 13 found and aspirated. If first culdocentesis attempt is not successful, the procedure can be repeated with a dif- ferent angle of approach. Although perforation of viscus is a possibility, the complication rate has been very low. Fresh blood that clots rapidly is probably secondary to traumatic tap, and the procedure can be repeated. If blood is aspirated, it should be spun for hematocrit and placed into an empty glass test tube to demonstrate the presence or absence of a clot. If pus is aspirated, send specimens for GC, aerobic, anaerobic, Chlamydia, Myco- plasma, and Ureaplasma cultures. Measure the pressures in the popliteal arteries by placing a BP cuff on the thigh. The pressures in the dorsalis pedis arteries (on the top of the foot) and the posterior tibial ar- teries (behind the medial malleolus) are determined with a BP cuff on the calf. Note: The Doppler cannot routinely determine the di- astolic pressure, and a palpable pulse need not be present to use the Doppler. It is equal to the pressure in the ankle (usually the posterior tibial) divided by the systolic pressure in the arm. Indications • Useful in the evaluation of chest pain and other cardiac conditions Materials 13 • ECG machine with paper and lead electrodes • Adhesive electrode pads Procedure 1. It is important to be- come acquainted with your particular machine prior to using it. Instruct the patient to lie as still as possible to cut down on artifacts in the tracing. The standard ECG machine has five lead wires, one for each limb and one for the chest leads. Newer machines have six precordial electrodes, which are all placed in the proper positions prior to performing the procedure. These may be color-coded in the following fashion: • RA: White—right arm • LA: Black—left arm • RL: Green—right leg • LL: Red—left leg • C: Brown—chest 13 Bedside Procedures 267 b. The limb electrodes are flat, rectangular plates held in place by rubber or Velcro straps that encircle the limb; newer machines may use self-adher- ing electrode pads. Place each electrode on the limb indicated, wrist or ankle, usu- ally on the ventral surface. In case of amputation or a cast, the lead may be placed on the shoulder or groin with almost no effect on the tracing. Newer machines allow all leads to be placed prior to running the ECG with all pads applied at the same time. Precordial leads are placed as follows: •V 1 = fourth intercostal space just to the right of the sternal border •V 2 = fourth intercostal space just to the left of the sternal border •V 3 = midway between leads V2 and V4 •V 4 = midclavicular line, above the fifth interspace 13 V1 V2 V6 V3 V5 V4 Midaxillary line Anterior axillary line Midclavicular line FIGURE 13–9 Location of the precordial chest leads used in obtaining a routine ECG. Once the machine is warmed up and the electrodes are positioned or ready for position- ing, make sure that the paper speed is set at 25 mm/s. When everything is ready, follow the directions for your particular machine to obtain the ECG tracing. The second rib inserts at the sternal angle, and therefore the second intercostal space is directly inferior to the sternal angle. Feel down two more intercostal spaces and you have the fourth intercostal space to position V1 and V2. When you start seeing a solid blue or red line at the top or bottom of the strip, you are about to run out of paper. Red and green go to the legs: “Christmas on the bottom” or “When driving your car you use your left leg to brake (red light) and your right leg to go (green light). Black (left) and white (right) go to the arms: “Remember white is right and black is left.

Even though the els of LD L cholesterol citalopram 20 mg with mastercard denivit intensive treatment, a fam ily history of heart disease 10 mg citalopram otc symptoms of colon cancer, physician is justified in im m ediately prescribing a and hypertension. O ther risks include being m ale, cholesterol-lowering drug to patients with very high sm oking, low levels of high density lipoprotein (H D L) blood cholesterol and additional risk factors, strong ad- cholesterol, diabetes m ellitus, hyperhom ocystinem ia, vice should also be given on the need and benefits of high levels of lipoprotein a (Lpa), and high blood levels adding life style changes. C-Reactive protein tion of body weight; decreased dietary total fat, choles- is a m arker for cellular inflam m ation. Furtherm ore, the Patients with statins decreased the risk of a first heart attack in sub- Hypercholesterolemia jects with even average LD L cholesterol levels. In addi- tion to decreased clinical expression of heart disease, LDL cholesterola aggressive lowering of blood cholesterol with the statin drugs can partially reverse atherosclerosis in the sense Treatment Initiation level M inimal goal of reducing the degree of stenosis (closure) of coronary guidelines (mg/dL) (mg/dL) arteries. G uidelines for initiation and goals of treatm ent D ietary treatm ent of hypercholesterolem ias are outlined in Table 23. W ithout CH D or two 160 160c other risk factorsb W ithout CH D and with 130 130d two or m ore other M ANAGEM ENT OF HYPERLIPIDEM IAS risk factorsb W ITH DRUGS W ith CH D 100 100 D rug treatm ent Drug Treatm ent of Polygenic and Fam ilial W ithout CH D or two 190 160 other risk factorsb Hypercholesterolem ia W ithout CH D and with 160 130 Statins two or m ore other risk factorsb M echanism of Action W ith CH D 130 100 The statin fam ily of six closely related hypocholes- LDL, low-density lipoproteins; CHD, coronary heart disease. The liver is their target risk because they already have definite CHD or because they have any two of the following factors: male sex, family history of organ, and decreased hepatic cholesterol synthesis ulti- premature CHD, cigarette smoking, hypertension, low high- m ately leads to increased rem oval of LD L particles from density lipoprotein (HDL) cholesterol ( 35 mg/dL), hyperho- mocysteinemia ( 16 M ), high plasma levels of Lpa ( 30 the circulation. A s a consequence, all other hypocholes- mg/dL), diabetes mellitus, definite cerebrovascular or peripheral terolem ic drugs have been relegated to secondary status. Clinical trials with lovastatin (M evacor), sim vastatin dRoughly equivalent to total cholesterol level 200 mg/dL. Lpa is a m od- 6-Year 10 ified LD L particle that is both atherogenic and pro- Death Rate 8 per 1000 Men throm bic. The risk of CH D is directly Key points (1) The risk increases steadily and particularly above 200 mg/dl. A n consequences of inhibiting the cholesterol synthesis overview of lipoprotein m etabolism and the sites where pathway. D rug-induced inhibition of hepatic cholesterol drugs can influence plasm a lipoprotein levels is pro- synthesis leads to lowering of liver cholesterol concen- vided in Figure 23. M any im portant m olecules be- statin is present at adequate concentration in the liver, sides cholesterol are generated by interm ediates in the the extra H M G CoA reductase activity is not ex- com plex cholesterol synthesis pathway. H owever, the increased hepatic LD L receptor the isoprenes geranylgeranyl and farnesyl, which are co- protein results in increased rates of rem oval of LD L valently attached to som e proteins (isoprenylation) and particles from the circulation by the liver, lowering of target them to m em branes where they function. The re- ENDOTHELIAL CELLS OF CAPILLARIES BLOOD PLASMA LIPOPROTEIN LIPASE CHYLOMICRON B48 SMALL INTESTINE E FATTY ACIDS GLYCEROL REMNANT B48 B 100 I LIVER E B100 ACETATE FATTY ACIDS GLYCEROL III E BILE VLDL DUCT IV II LYSOSOME E CHOL B100 V VI E B100 VLDL BILE REMNANT ACID (IDL) E EXTRAHEPATIC TISSUES B100 LDL (RECEPTOR-MEDIATED UPTAKE) FIG U R E 23. I, stimulation of bile acid and/or cholesterol fecal excretion; II, stimulation of lipoprotein lipase activity; III, inhibition of VLDL production and secretion; IV, inhibition of cholesterol biosynthesis; V, stimulation of cholesterol secretion into bile fluid; VI, stimulation of cholesterol conversion to bile acids; VII, increased plasma clearance of LDL due either to increased LDL receptor activity or altered lipoprotein composition. Clinical Uses W ith the possible exception of atorvastatin, the statins are used to lower LD L cholesterol in fam ilial or polygenic ( m ultifactorial) hypercholesterolem ia (type IIa) and in com bination with triglyceride-lowering drugs to treat com bined hyperlipidem ia (type IIb) when both LD L and VLD L (very low density lipoproteins) are elevated (Table 23. H owever, the statins probably should not be given with the fibrates (triglyceride- lowering drugs, discussed later), since this com bination m ay greatly increase statin toxicity. This effect m ay be due to decreasing hepatic choles- terol and cholesterol ester levels to such an extent that hepatic form ation of VLD L is im paired. The statins also have been claim ed to reduce blood cholesterol levels m odestly in som e patients with hom ozygous fam ilial hy- percholesterolem ia, a condition often fatal in childhood density in postm enopausal wom en. Lovastatin decreased elevated plasm a levels of C- reactive protein, a m arker for cellular inflam m ation, and Adverse Effects acute coronary events in patients with relatively low The statins generally appear to be well tolerated, plasm a cholesterol levels. Recent studies also suggest with m uscle pain and liver dysfunction seen in 1 to 2% that use of statins m ay decrease the risk of stroke, de- of patients. Fam ilial com bined IIb LD L,VLD L Chol,TG Increased VLD L production, in- CH D, stroke hyperlipidem ia creased conversion of VLD L to LD L. Fam ilial dyslipo- III ID L ( -VLD L) Chol,TG D ecreased plasm a clearance of CH D, stroke proteinem ia VLD L and chylom icron rem nants due to abnorm al A po E (E2 for norm al E3). Fam ilial hypertri- IV VLD L TG O verproduction of VLD L; low LPL Pancreatitis, CH D glyceridem ia activity. Type I is a rare elevation of chylomicrons treatable only by diet (removing long chained fatty acids).

Experientially order 20mg citalopram with visa medicine dispenser, both may involve a search for meaning and purpose 40 mg citalopram otc medications like zoloft, transcendence, connectedness and values. Spirituality may also have communal or group expression; when this Complementary therapies in neurology 224 5 expression is formalized, spirituality is more like an organized religion. Because of this overlap, religious involvement and spirituality are considered together in this chapter. Religion and spirituality are among the most important cultural factors that give 6 structure and meaning to human values, behaviors and experiences. Surveys of the general population and of patients have 8 consistently found that more than 90% of people believe in a Higher Being. One survey found that 94% of patients regard their spiritual health and their physical health as equally important. Most patients want their spiritual needs met and would welcome an 8,10,11 inquiry regarding their religious and spiritual needs. Finally, a survey of family 12 physicians found that 96% believe spiritual wellbeing is an important factor in health. Despite these findings, the spiritual needs of patients are often ignored or not 8,9,13 satisfied (Mayo Patient Expectations Survey, unpublished data, 1994). Nevertheless, clinician interest in patient spirituality has increased because of a growing number of studies that have shown an association between increased religious involvement and 14 spirituality and better health outcomes. This chapter reviews the results of published studies, meta-analyses, systematic reviews and subject reviews that have examined the association between religious involvement, patient spirituality and spiritual interventions (e. Finally, suggestions on how clinicians might ethically assess and support the spiritual needs of patients are provided. Furthermore, intercessory prayer studies have significant methodological flaws, making their relevance to clinicians 15,16 unclear. USE OF RELIGIOUS AND SPIRITUAL VARIABLES IN MEDICAL RESEARCH Religious and spiritual variables are not widely used in medical research. For example, a 17 review of 2348 studies published in four major psychiatry journals between 1978 and 1982 revealed that only 59 (2. Neglect of religious and spiritual variables in medical research may be attributable, in part, to the reliance on the biomedical model in which physical evidence is paramount. While the biomedical model is excellent for describing certain disease mechanisms (e. Religious involvement, spirituality and medicine 225 Of the studies that have considered the effects of religious or spiritual factors on health, most have used measures of religious involvement (e. The main reason for this practice is the greater consensus on how to define and measure religious involvement as opposed to spirituality. RELIGIOUS INVOLVEMENT, SPIRITUALITY AND PHYSICAL HEALTH A majority of the nearly 350 studies of physical health that used religious and spiritual variables have found that religious involvement and spirituality are associated with better 25 physical health outcomes. Mortality During the past three decades, at least 18 prospective studies have shown that religiously 26–43 involved persons live longer. The populations examined in these studies included not only entire communities but also specific groups. The religious and spiritual variables 29,31,34 used in these studies included membership in a religious congregation, attendance 26–28,30,32,33,35,36,38–42 37 at religious Services, living within a religious community and self- 43 44 reported religiosity. One study of hospitalized veterans, however, found no relationship between religious involvement, religious coping and mortality. In addition, a 45 2-year longitudinal cohort study of nearly 600 patients aged 55 years or older found that religious struggle with illness (e. Recent prospective studies have carefully controlled for potential confounding 46 38 variables. A 28-year study of 5286 adults (aged 21–65 years) found that frequent (once per week or more) attenders of religious services were 23% less likely than non- attenders to die during the follow-up period (relative hazard 0. Notably, this study also found that mobilityimpaired persons were more likely to be frequent attenders than non- 39 attenders. A 5-year study examined the same relationship in 1931 adults (aged 55 years or older). Frequent attenders were 24% less likely to die than nonattenders during the follow-up period (relative hazard 0.

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