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A—Autoimmune disorders include multiple sclerosis and the various collagen diseases that may affect the brain buy provera 2.5 mg with mastercard womens health institute taos. T—Traumatic disorders include epidural and subdural hematomas buy provera 5 mg women's heart health tips, intracerebral hematomas, and depressed skull fractures. I—Inflammatory disorders associated with pyramidal tract signs include encephalomyelitis, abscess, and basilar meningitis. N—Neoplasms in the brainstem are similar to those in the cerebrum but also include the acoustic neuroma, colloid cyst of the third ventricle, and chordomas. D—Degenerative disorders include syringobulbia, lateral sclerosis, and Friedreich ataxia. C—Congenital disorders with pyramidal tract involvement in the brainstem include platybasia and Arnold–Chiari malformation. A—Autoimmune disorders bring to mind multiple sclerosis and other 136 demyelinating diseases. T—Traumatic disorders include basilar skull fracture and posterior fossa subdural hematoma. E—Endocrine disorders of the brainstem prompt recall of an advanced chromophobe adenoma or craniopharyngioma. Spinal Cord V—Vascular lesions of the spinal cord are anterior spinal artery occlusion and dissecting aneurysm of the aorta. I—Inflammatory lesions of the spinal cord include epidural abscess, transverse myelitis, and meningovascular lues. N—Neoplasms of the spinal cord include neurofibromas, meningiomas, and metastatic tumors. D—There are a large number of degenerative diseases that affect the pyramidal tracts. These include amyotrophic lateral sclerosis, syringomyelia, subacute combined degeneration, and Friedreich ataxia. I—Intoxication will help recall radiation myelitis and the side effects of spinal anesthesia. C—Congenital disorders of the spinal cord include arteriovenous malformations and diastematomyelia. Cervical spondylosis associated with a progressive myelopathy is often associated with a congenital narrowing of the cervical spinal canal. A—Autoimmune helps recall multiple sclerosis as a common cause of pyramidal tract lesions in the spinal cord. T—Trauma will help recall fractures, epidural hematomas, and ruptured discs that compress the spinal cord. E—Endocrine disorders do not usually affect the spinal cord and pyramidal tracts unless there is metastasis from an endocrine tumor to the spine. If there are obvious cranial nerve signs, the imaging study will include the brain and brainstem. Spinal cord lesions usually require x-ray of the spine and possibly myelography and spinal fluid analysis. Examining each of these physiologic mechanisms provides a useful recall of the differential diagnosis of anorexia. Psychic desire for food: This may be impaired in functional depression, psychosis, anorexia nervosa, and organic brain syndromes (e. Decreased pancreatic enzymes: Pancreatitis, fibrocystic disease, pancreatic carcinomas, and ampullary carcinomas are considered here. Proper bile secretion: Gallstones, cholecystitis, cholangitis, liver disease, and carcinoma of the pancreas and bile ducts must be considered here. Smooth absorption of food: Celiac disease and the many other causes of malabsorption are brought to mind in this category. Smooth transport of food and oxygen: Anything that interferes with oxygen and food reaching the cell may be considered here. Uptake of food and oxygen by the cell: This will be decreased in diabetes mellitus (when there is no insulin to provide the transfer of glucose across the cell membrane); in hypothyroidism (when the cell metabolism is slow, uptake of oxygen and food is also slow); in adrenal insufficiency, where the proper relation of 140 + − + sodium (Na ), chloride (Cl ), and potassium (K ) is interfered with; in uremia, hepatic failure, and other toxic states from drugs that interfere with cell metabolism; and in histotoxic anoxia, where the uptake of oxygen by the cell is impaired (e. Chronic infections such as pulmonary tuberculosis may also produce anorexia by this mechanism. Approach to the Diagnosis Loss of appetite usually is related to one of four things: (i) a psychiatric disorder, (ii) an endocrine disorder, (iii) a malignancy, or (iv) a chronic disease. If the general physical examination is normal, it is wise to get a psychiatric consult at the onset. The organic causes of anorexia are usually associated with significant weight loss. The combination with anorexia of other symptoms and signs will help make the diagnosis. If liver disease is suspected, a liver profile or hepatitis profile may be ordered. If malabsorption syndrome is suspected, one can order a D-xylose absorption test or quantitative stool fat analysis. Nasal passages: Focusing on the nasal passages, one can recall upper respiratory infections, allergic rhinitis, chronic rhinitis of smoking and/or overdose of decongestants, polyps, sinusitis, and nasopharyngeal carcinomas. Olfactory nerves may be affected by fracture of the cribriform plate or neoplasms. The olfactory groove may be affected by trauma, neoplasm (particularly a meningioma), or cerebral abscess. Cerebrum: Considering the cerebrum will prompt the recall of general paresis, encephalitis, basilar meningitis, multiple sclerosis, and tumor of the frontal lobe. Unfortunately, this method will not help recall the various drugs such as captopril and penicillamine that may cause anosmia. It will also not prompt the recall of hysteria and various systemic diseases (hypothyroidism, diabetes, renal failure, hepatic failure, and pernicious anemia). If the disorder is the result of an acute infectious process, nothing needs be done. It is essential to rule out drug and alcohol use at the outset by a careful history and urine screen. A good nasopharyngeal examination and nasopharyngoscopy must be done if local disease is suspected. The causes may be divided into prerenal (where less fluid is delivered to the kidney for filtration), renal (where the kidney is unable to produce urine because of intrinsic disease), and postrenal (where the kidney is obstructed and the urine cannot be excreted). Prerenal causes: Anything that reduces the blood flow to the kidney may cause anuria. Thus, shock from hemorrhage, myocardial infarction, dehydration, drugs, or septicemia may be the cause. Intestinal obstruction or intense diarrhea may cause the loss of enormous amounts of fluid through vomiting or diarrhea, and the accompanying shock results in anuria.

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Without conscience: The disturb- of the Levenson Self-Report Psychopathy Scale: Is ing world of the psychopaths among us order 5 mg provera with amex womens health of central ma. Superego: An attachment perspec- traits buy generic provera 10 mg line menstruation smell, and prosocial moral reasoning: A multicul- tive. Purpose in life as psychopathology: Analysis of spontaneous descrip- a predictor of mortality across adulthood. Psycho- tions of self and significant others in patients with logical Science, 25, 1482–1486. Journal of Personality ment, psychopathology, and the therapeutic pro- Assessment, 96, 465–470. Perspectives on Psycho- research using the Personal Orientation Inven- logical Science, 8, 272–295. Flow: The psychology personality: Psychodynamics, cognitive style, and of optimal experience. Perspectives on Psychological ceptualizing and measuring humility as a personal- Science, 4, 422–428. Annual Erikson’s healthy personality, societal institu- Review of Psychology, 58, 345–372. Psycho- son Centered and Experiential Psychotherapies, 8, logical Bulletin, 126, 748–769. The intent is to elaborate on a patient’s subjective experience of the symptom pattern. We depict individual subjectivity in terms of affective patterns, mental content, accompanying somatic states, and associated relationship patterns. To have an overview of the mental health field, it is essential, in addition to sim- ply listing their symptoms, to consider the subjective lived experience of people with psychiatric disorders. Subjective experiences have been particularly neglected, since 134 Symptom Patterns: The Subjective Experience—S Axis 135 the usual methodologies of “descriptive” or “categorical” psychiatry are not adequate to reflect the complexity of human subjective experience in pathological and non- pathological conditions that may need attention and/or treatment. People in the same diagnostic category, with similar symptoms, may still vary widely in their subjective experience, and these variations have implications for treatment. A deeper exploration would be expected to merge some diagnos- tic categories and differentiate others. This chapter on symptom patterns is placed third in our overall diagnostic profile for adulthood because such patterns are best understood in the context of a patient’s overall personality structure and profile of mental functioning. Symptoms such as anxiety, depression, and/or impulse-control problems may be part of an overall emo- tional challenge. For example, problems with impulse control and mood regulation are common in patients with the larger developmental deficit of inability to represent (symbolize) a wide range of affects and wishes. In some instances, notably those in which there has been long-standing psycho- analytic scholarship, we comment on psychodynamic understandings of a given symp- tom pattern and include general implications for treatment, transference, and counter- transference. Differential Diagnosis of Certain Subjective Experiences Some symptoms, such as fear, anxiety, and sadness, are universal, and consequently also common in most psychiatric disorders and nonpsychopathological conditions. Symptoms may have specific interactions, such as those delusions that derive from hallucinations. These anomalous subjective experiences are most often psychological (“psychogenic,” 136 I. Thus substance-mediated symptoms and symptoms caused by another medical condi- tion should always be considered. These are the most common unpleasant subjective states and may appear in almost any disorder. When they are relatively monosymp- tomatic, pronounced, or specific, an anxiety or depressive disorder can be diagnosed. When their absence seems perplexing, then a search for a “primary gain” or for a specific mental functioning (examples include emotional blunting, isolation of affect, la belle indifférence, dissociation of affect, etc. These may be direct bodily expressions of emotional pain, especially in persons not psychologically minded. Symptoms may include tactile posttraumatic flashbacks of real past events, whose origins are murky because auto- biographical memory and context are missing. They may be somatic “betrayals” of unacceptable repressed impulses, as in classic conversion disorders. Negative somato- form symptoms, such as conversion anesthesia for sharp pain, commonly accompany self-mutilation and worsen its prognosis. These may be (in decreasing order of frequency) auditory, tactile, visual, olfactory, or gustatory. Visual hal- lucinations may also occur in many of these disorders and in depersonalization dis- order (as in out-of-body experience). Tactile hallucinations (negative and positive) are especially common as components of posttraumatic and dissociative psychopathology. Olfactory and gustatory hallucinations are likewise often posttraumatic or dissocia- tive, but may also be organic. These may occur in toxic or epileptic psychosis, schizophrenia, brief psychotic disorder, mania, melancholia, delusional disorder, or very severe personal- ity disorders (transiently), without calling for another diagnosis. Hallucinating one’s own thoughts aloud may lead to the delusion of thought broadcasting. The negative hallucination of feeling unreal or alien may lead to the delusion of being an extraterrestrial. Symptom Patterns: The Subjective Experience—S Axis 137 •• Suicidal ideation, behavior, attempts. These are typical “cross-sectional” symptoms, attitudes, and behaviors; thus they may be present in many disorders at different times, as most of the psychodynamic and biological literature points out. Suicidal risk should be carefully assessed for any patient, regardless of the “primary diagnosis” or the patient’s primary treatment request. In addition, the subjective expe- rience of suicidal thoughts or behavior may vary widely within the same patient in the course of his or her life or treatment, and it should always be considered as one of the primary risk factors for suicidal attempts. Developmental Context Even in adults, developmentally relevant aspects of symptom patterns interact with personality variables. A depression in an elderly woman may be experienced quite dif- ferently from a depression in a woman in her thirties, and it may consequently call for a different therapeutic approach. A formulation and treatment plan should recognize such age-related differences in addition to the patient’s history, individual life/rela- tional events, and social, economic and cultural context. Temporal Aspects of the Current Condition Why are these symptoms occurring now, and what do they mean? One technique is to wonder about the first and worst: If a man is depressed, when does he remember being depressed like this for the first time? Bimodal Symptoms Some symptoms were present at some discrete time in the past and reappear today. It may have been any item of “unfinished business” (fixation) from a person’s past, which becomes reactivated under stressful conditions or spe- cific life events—regression to a point of fixation—especially if the trigger has some thematic affinity to the original item.

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The routine physical examination requires an examination of the external genitalia and rectal and vaginal examination trusted 10 mg provera zeid women's health center. Some women state that they just had their annual Papanicolaou (Pap) smear buy genuine provera on-line breast cancer tattoos, but if they have come for a complete physical examination, it is necessary to do at least a manual examination. Besides, the gynecologist may not have completed a thorough manual examination when doing the Pap smear. For an obese woman in whom one cannot palpate the adnexa adequately, it is necessary to order an ultrasonic examination. It is possible to detect many diseases by looking at the nails, such as the clubbing in congenital heart disease, chronic obstructive pulmonary disease, and bronchiectasis; the thickening in hypothyroidism; and the spoon nails in iron deficiency anemia. Most physicians rely on nurses and other health care professionals to take blood pressure. Unless these nurses have received your instructions about the auscultatory gap, this is not a good idea. The author teaches health care professionals in his office to take blood pressure with the radial pulse first before applying the stethoscope. The clinician should not forget to check for axillary and inguinal adenopathy and peripheral pulses. If the dorsal pedis and posterior tibial pulses are absent, he or she needs to check the femoral arteries for absent pulses or bruits. Unless a clinician is a neurologist, he or she is not going to perform a thorough neurologic examination during the routine physical examination unless the patient’s complaints are definitely neurologic. Here is an abbreviated examination that may be useful if there is simply no time to do a thorough examination: Check coordination by having the patient pat the physician’s hand with each of his or her hands and feet in rapid succession. Now, check for weakness or hemiparesis by having the patient grip the physician’s fingers with each hand and dorsiflex and plantar flex his or her feet against resistance. Check sensation in all four extremities with a tuning fork, preferably a 128-cps one. Check for simultaneous stimulation by seeing if the patient can recognize the physician’s fingers on one or both extremities at the same time. Check the cranial nerves, beginning with the funduscopic examination (which you have already done); have the patient follow a light; and check the gross visual field by confrontation, pupillary equality, and response to light. Check facial nerve function by telling the patient to close his or her eyes and whistle and then watch to see if the patient can extend his or her tongue in the midline. The examination is not finished until the physician has checked for the symmetry of the physiologic reflexes on all four extremities and plantar responses on the feet. The author realizes that this still seems like a lot; however, there are no other shortcuts to a good neurologic examination. If the readers have any pearls that they would like to share, they are encouraged to write to the author (care of Wolters Kluwer 38 Health/Lippincott Williams and Wilkins), so that they can be included in the next edition. Additional clinical techniques for evaluation of patients with many common symptoms and signs will be discussed here. They are the result of the author’s many years of experience in clinical practice as well as reviewing a host of textbooks on physical diagnosis. Although some of these techniques will be familiar to the reader, many will not be. Note that these symptoms and signs are organized into the five categories used in the review of systems: pain, lumps and bumps, bloody discharge, nonbloody discharge, and functional changes. The author hopes that the reader enjoys this fresh approach to the physical examination. No matter what portion of the abdomen is involved in the complaint, the physician must look for rebound tenderness. One applies pressure to the abdomen where the pain is located and then suddenly releases it. If the patient winces, there is rebound tenderness and a serious abdominal condition. If the right testicle is retracted, there is a possibility of a ruptured appendix. When both testicles are retracted, peritonitis from a perforated peptic ulcer or pancreatitis is likely. Place your thumb under the right subcostal margin and have the patient take a deep breath. Do not forget to check for inguinal and femoral hernias as well as umbilical and incisional hernias. The finding of occult blood in the stool may point to intussusception or mesenteric infarct, as well as peptic ulcer disease and neoplasm. Applying pressure in the left lower quadrant causes pain in the right lower quadrant. Arm and Hand Pain The patient presenting with acute arm and hand pain should usually be no problem. Perhaps the clinician will miss referred pain from acute coronary insufficiency, but this is not likely. It is chronic recurrent pain in the arm and hand that often confounds the clinician. Next, look for tenderness of the radial–humeral joint (tennis elbow) and lateral epicondyle (golfer elbow). If these techniques fail to reveal the diagnosis, it is time to look for the neurologic causes of the pain in four places: Begin by palpating the cervical roots and performing a cervical compression test and Spurling test. Sensation to touch and pain should be reduced in the little finger and the lateral one-half of the ring finger if this is present. Finally, tap the medial surface of the wrist (Tinel sign), and flex the wrist for 3 minutes (Phalen test) to pin down the diagnosis of carpal tunnel syndrome. Sensation to touch and pain will be diminished in the first three fingers and the medial one-half of the ring finger if this is present. Obviously, a neurologist will perform a more detailed examination, but a primary care physician should be able to pick up most causes of chronic 41 arm or hand pain using these techniques. Chest Pain The author has no doubt that the reader will do an adequate job of auscultation and percussion of the heart and lungs in cases of chest pain. The author recently had a case of carcinoma of the lung where the only clinical sign was tracheal deviation to the side of the lesion. In addition, remember to Palpate the costochondral junctions to rule out Tietze syndrome. Above all, it is essential to remember to check the lower extremities for signs of thrombophlebitis such as a positive Homan sign. Dysuria Many cases of dysuria are associated with a urethral or vaginal discharge, so the techniques used to evaluate these complaints apply here (see pages 9 and 10). In male patients presenting with dysuria alone, the physician will want to massage the prostate to determine if there is chronic prostatitis. If a discharge is produced by this procedure, even a small amount, the patient probably has prostatitis. One can confirm the diagnosis by putting a drop on a slide and examining for white blood cells under the microscope.

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The traction and coun- Excision tertraction manipulation should be well coor- After creating a suffcient area of working space generic 5 mg provera with mastercard womens health tampa, dinated by appropriate handling of the a self-retaining retractor is placed to maintain the Yankauer suction tip or endoscopic dissector height for robotic arms docking (Figs buy provera online now pregnancy 0-3 months. Subcapsular delineated from the surgeon’s console (Left-sided dissection is continued with Harmonic curved shears or approach) monopolar cautery until the proximal portion of the facial artery is identifed. The vessel can be ligated either by Harmonic curved shears or Hem-o-lok ligation system (Telefex Inc. Koh a b Mylohyoid muscle Submandibular ganglion Lingual nerve c d Lingual nerve Hypoglossal nerve Submandibular duct Fig. Other types of neck dissection can be performed by selective modifcations of these two procedures. The marginal branch of the facial nerve is identifed by visual- izing the facial vessels around the mandibular notch. The nerve is handled with extreme care while dissection of the perifacial lymph nodes is done. After ligation of facial artery and vein, the lymphoadipose tissues inferior to the parotid tail are dissected (Left-sided approach) * Fig. The inferior Internal jugular vein extent of the dissection is the omohyoid muscle, and the medial extent is the midline strap mus- Spinal accessory nerve cles. Here, the specimen can be either removed or pushed aside to continue the robotic dissection (Left-sided approach) Fig. After recognizing the posterior belly of the digastric muscle, the previously dissected proximal facial artery at the posterior portion of the submandibular gland is ligated with Harmonic curved shears or Hem-o-lok ligation sys- tem (Right-sided approach) 12 Robot-Assisted Neck Surgery 117 Wharton’s Mylohyoid muscle duct Mylohyoid muscle Submandibular ganglion Lingual nerve Fig. The resulting postsurgical approach) feld is irrigated and thoroughly checked for any bleeding points, and a closed suction drain is inserted posterior to the hairline, and then the skin is closed with simple inter- rupted sutures (Right-sided approach) 118 H. When level I is omitted in the proce- the posterior belly of digastric muscle is identi- dure, the skin fap does not have to be as high up fed below the submandibular gland, and it is fol- as to the inferior margin of the mandible. It would lowed posteriorly to locate the internal jugular only increase the chance of direct/indirect mar- vein. The dissec- carotid sheath dissection, appropriate maneuvers must be tion is continued medially until it meets the carotid sheath provided by the assistant surgeon to maintain an appropri- (Right-sided approach) ate traction-counter traction force balance to aid the dis- section procedure. The previously dissected tissue of level injury) Va is grasped with the robot, and dissection is • Wound infection, dehiscence conducted superiorly to inferiorly. As the level of • Ischemia or necrosis of skin fap dissection reaches level Vb, the specimen is retracted medially, and the dissection continues The potential complications are similar to to meet the omohyoid muscle which is conse- those from a conventional open neck operation. The surgeon should pay special The postsurgical bed is irrigated and bleeding attention when dissecting around level I to avoid control done, before placing a closed suction direct/indirect injury to the facial nerve. The surgical wound is then sutured with causes of indirect injury to the marginal mandib- simple interrupted sutures. A comprehen- nifcant difference between a right-sided and a sive knowledge and familiarizing the local surgi- left-sided surgery; however, the dominant-sided cal anatomy and a suffcient amount of surgical surgery may be more comfortable to perform for experience are prerequisites to minimize such the robotic surgeon. Hair loss can occur along the skin incision within the hairline, but this can be minimized by • Nerve injury beveling the incision at this portion. Robotic facelift thyroidectomy: tumors can also be removed robotically by the facilitating remote access surgery. Robot-assisted thereby minimizing the role of the assistant sur- Sistrunk operation via a retroauricular approach for thyroglossal duct cyst. Robot-assisted the robotic dissection can be now be conducted selective neck dissection via modifed face-lift right after the working space creation, since an approach for early oral tongue cancer: a video demon- extra robotic arm will provide more comfortable stration. Most recently, selective neck dissection in parotid gland cancer: pre- there are expectations that there will emerge a liminary report. Robot-assisted selec- system which will take the robotic neck surgery tive neck dissection combined with facelift parotidec- tomy in parotid cancer. Robotic-assisted neck surgery be easier to learn and practice, but the dissection in submandibular gland cancer: prelimi- surgical skill itself could be further refned by nary report. Robot-assisted supraomohyoid neck dissection via a modifed face- lift or retroauricular approach in early-stage cN0 squamous cell carcinoma of the oral cavity: a com- parative study with conventional technique. Robotic facelift thy- robot-assisted neck dissection via a retroauricular or roidectomy: I. Preclinical simulation and morphomet- modifed facelift approach in head and neck cancer: a ric assessment. Qualitative and quantitative dif- with modifed radical neck dissection via unilateral ferences between 2 robotic thyroidectomy techniques. These tumors are most commonly man- aged by surgical resection via transcervical or M. The effcacy and The Laboratory for Applied Cancer Research, limitations of these approaches are well estab- Department of Otolaryngology Head and Neck lished [1–3]. The 5 mm robotic-guided arms enable Research, The Technion, Israel Institute of an assistant to introduce additional instruments Technology, Haifa, Israel into the operating feld to aid retraction, suction, Department of Otolaryngology, Rambam Medical and cauterization. This approach is expected to Center, The Technion, Israel Institute of Technology, Haifa 66036, Israel reduce tumor spillage and morbidity, to shorten e-mail: ziv@baseofskull. The prestyloid compartment contains the retro- mandibular portion of the deep lobe of the parotid b gland, adipose tissue, and lymph nodes associ- ated with the parotid gland. Physical examination should include palpation of the neck and the parotid gland in search of lymph Fig. The extent of the oropharyngeal mass patients with minimal surgical morbidity [8]. In should be evaluated with fexible fber optic eval- this chapter, we describe the indications and sur- uation of the oropharynx. If a malig- the skull base superiorly to the greater cornu of nant tumor is suspected, radiological staging is 13 Transoral Robotic Resection of Parapharyngeal Space Tumors 125 completed using a positron emission tomogra- eration. Surgeons must be acutely aware of a more medial position of the carotid artery as it passes through 13. A 0° 8°mm cam- When radiographic studies are diagnostic of a era is installed and inserted to the mouth. The robotic arms are positioned so that instrument tips are within the feld of view of the endoscope with minimal 13. As such, they are approximately par- allel to the optical arm, minimizing collision with 13. An assistant is positioned at the head of the The patient is placed in a supine position and is bed. The assistant must be familiar with endo- nasally intubated via the contralateral nostril. The scopic techniques since he will be working off of operating table should be positioned with the the screen rather than by direct visualization. The robot to troubleshoot device failures and interfer- patient should be positioned in the patient supine ence of the arms. A 2-0 silk suture The procedure is initiated with an incision over through the anterior tongue is placed for retrac- the prominent aspect of the mass, through the tion to maximize exposure; gauze is positioned oropharyngeal mucosa, from superior to inferior. Traction mass is grasped and pulled medially to assist and countertraction are important for dissecting with the lateral dissection (Fig. The more cephalad medial pterygoid identifed, and dissection proceeds along the muscle may be visualized, and further lateral mass (Fig. As mucosal faps are developed, dissection should be avoided to minimize expo- lateral retraction of the anterior tonsillar pillar sure of the carotid artery.