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Losses decrease with renal failure See Management of Mild-Moderate Dehydration buy 10 mg female cialis otc, page 650 Adult requirements Adult daily requirements: 2 female cialis 10 mg on-line. Maximum rate of potassium replacement is 20 mmol/hr Burns Burns rapid loss secondary organ damage (e cheap female cialis 20mg amex. Red cell transfusions transfuse at 1 unit per 2 4 hours (if th th 552 4 and 5 Year Notes cardiovascularly healthy then 2 hours, if older then 4 hours as you dont want to go too fast otherwise volume overload) Platelet concentrates: Prophylactic platelet transfusions 10 g/L pretty good maintenance level in leukaemia. Not the same as below the normal range, as normal range includes functional reserve) What is the appropriate blood product What is the correct dose to transfuse Has the transfusion worked? Intermittent flushing with saline helps If hemiplegia, or mastectomy, insert in good arm Infiltration/tissuing is leakage into surrounding tissues. Obtain verbal consent Choice of gauge: age, flow required, whats being infused. Malnourished need feeding Enteral Nutrition Adult energy requirements: 40 Kcal/kg/day (approx. Stop at night if they can tolerate increased flow during day Tradeoffs: When sick, motility and emptying. Need to be minimal volume but still flow through tube Dont include lactose as lactase when sick. Fat a good way of giving calories without glucose (which could diabetes) Other major risk: sepsis. Colony count should be 5 times higher in central line sample than in peripheral blood Metabolic problems common, e. Depends on depth, if its loculated or presence of overlying bowel Peripheral line Central line: may look innocent but consider if no other locus found. Treat with naloxone (but short T so may need to repeat) Delirium tremens (alcohol withdrawal) Urinary retention No cause found Management: Quiet, gently lit area, familiar faces. Dont use dextrose wont stay in the blood for long Surgical and Fluid Management 557 Dehiscence = Wound breakdown (eg of a gut anastamosis). Increased over all groups from 1986 to 1996 Maori and Pacific Islanders also more likely to not have a car, share a household, less likely to leave school with a qualification Mortality: Under 5 mortality currently around 500 per annum Age specific rates: 7/1000 live births for 0 1 years, 0. See Development Chart: normal development from 0-60 months, page 576 Paediatrics 563 Past medical history Social/school Medications Allergies Family History: ages and health of parents and grandparents. Dont wear stethoscope around neck Show them what you want rather than telling them Blood pressure: Is important always do it Getting them calm is hard usually anxious artefacts common Cuff: Bladder should nearly encircle the arm. Width is 2/3 length from should to elbow Chest exam: Percussion more sensitive than auscultation (wont show anything in the absence of respiratory signs/symptoms) Percussion will tell you about hyperinflation, fluid, mediastinal shift Ausciltate heart early in the exam but not first Abdominal exam: Get child to suck in and push out tummy to check for tenderness then you wont have to hurt them yourself. Dont press too hard moves with respiration th th 564 4 and 5 Year Notes Pelvic organs higher (eg bladder) Pulses: Radial/ Brachial take both sides. Due to obstruction or sympathetic discharge, eg due to pain (not necessarily abdominal could be a torted testicle) Decreased urine output (wet nappies < 4 per day) Diarrhoeal losses Dysuria and pale extremities may be the only warning signs before they crash Factors which discriminate on exam: Floppiness: tone Perfusion: pale, mottled or blue, cold. Changing behaviour requires: Knowledge: necessary but not sufficient Skills: to manage the change Motivation: Involves striving towards a goal, not just trying. Make it easy Good counselling technique: Open-ended questions: tell me about. E hua whakatairantitia Rere ki uta, rere ki tai Mau e ki mai He aka te mea nui o te ao? Maki e ki atu, He tangata, he tangata If you pluck the young shoot of the flax bush, where will you find the bellbird? Read books about hospital Reassure your child that you will be there too Answer your child questions Use simple terms that the child can understand Take a favourite toy. Vertical cut down back of head Can I take my baby home afterwards yes Autopsy may provide: A cause of death but may take time Identify unacceptable iatrogenic lesions Quality control for a neonatal unit Assist medical knowledge Information that may help other babies Paediatrics 569 Common reasons for refusal: Concerns about disfigurement and further suffering Lack of information Objections from family members Religious beliefs Interference with funeral arrangements Must refer to the coroner: Where death certificates cannot be signed Thought to be related to an invasive procedure ? Birth asphyxia Deaths thought to be related to an instrumental delivery Behavioural Issues Behaviour doesnt exist outside an environmental context Behaviour Management History Taking: Antecedent: what sets him off? Somewhere safe and boring, and where you dont mind the child disliking (ie not the toilet if toilet training or bedroom if sleep training). Indicators of serious disturbance include: Deliberate self harm or messing Wandering off Running away Age inappropriate sexual behaviour Developmental sequence of everyday habits: Feeding Sleeping Eating Toilet Paediatrics 571 Going to bed and getting up Dressing and undressing Washing and cleaning teeth Aim is to achieve regular habits and routines: To start with need to insist on regular routine and time schedule. Once achieved can be more flexible Failure to achieve routine: daily hassle and distress Regular routines security of child, argument with parents Factors which behaviour problems: Routine and regularity Clear limit setting Unconditional love and affection High level of supervision Consistent care and protection Age appropriate disciplines and rewards Tantrums: Want their way. If you say no, will have to stick with it choose your battles Options for managing a tantrum (see Behaviour Management, page 570) Ignore it: eg leave the room Time out Distract Avoid problem areas (eg supermarkets) Things will get worse before they get better. At risk when the parents perceive the child is vulnerable Autonomy: Development of independence ( social competence) Paediatrics 573 Mastery: increasing sense of competence over the physical environment Together autonomy and mastery lead to an internal locus of control. Struggles for autonomy and mastery produce normal tantrums Types of Attachment Disorder: Disinhibited type: will go to anyone. Violence is used to reinforce this Screening questions: I have seen many people who come to see me with problems like yours. In my experience, many of these women are being hurt in some way by their partner. Developmental assessment Indirect assessment of the acquisition of life skills Establish rapport: use names a lot, thanks for coming, etc more valid assessment History: Current development and time course of development Order of questions should be: When asking about milestones, start with things he is likely to be able to do and work up. Get better rapport than starting at the upper limit and working down Hearing: What things can he hear? Count bricks Plurals 42 mo: fetch several items Name friend Pedal; Up stairs adult Share, turns Hop 3 steps/ Jump off 2 5 brick gate Intelligible to strangers Prepositions: between Gives age Undress indep. Instead, does he do age appropriate work, need extra tuition, etc Cognitive Development Overall process: Autonomy: dependent on parents peers independent Abstract thinking (what if? Usually (80%) non-disjunction at first meiotic division 5% have different karyotypes: Mosaic Down: 3 % Robertsonian translocation t14:21: 4. Chromosomal anomalies represent 15% of congenital anomalies Risk: Maternal age at birth Down in live births 25 - 29 1:1100 30 1: 900 35 1:350 37 1:200 40 1:100 43 1:50 45 and over 1:25 Neonatal Screening: Only 30% of children with Down are born to women over 35. Boys = 3 * girls 75% show some degree of general intellectual impairment Aspergers Syndrome: Symptoms overlap with autism Social interaction and behavioural problems similar to autism but not associated with significant language or intellectual delay Effect of Chronic Disease on Development See also Chronic illness and disability in Adolescents, page 669 10 15 % of children have some chronic health condition. See Attachment Disorder, page 573 For the toddler: Watch for vulnerable child syndrome: continued parental concern after child has recovered adverse affects on child. More complicated when some ongoing vigilance is required Support appropriate attitudes and plans Mobilise family support Remain optimistic If in hospital, use separations to reinforce that parents will return. Devastation of silence Denial can also be a coping mechanism Develop an acceptance of a new identity through the crisis: Seeing how the child is different Finding positives in this new identity and helping the family value these Achieve a sense of movement through the crisis. Mark positives and achievements of the family Encouraging compliance: For the highly compliant: teaching, directions For the non-compliant (those who respond yes but. Male = female + 13 cm or average their centiles) Family history: eg constitutional delay Systems Psychosocial Development Examination: Growth parameters Dysmorphic features ? Child more vulnerable to pain and stress-induced exacerbations Occurs at least monthly for a three-month period.

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With aerobic exercise generic 10mg female cialis overnight delivery, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group [51] buy discount female cialis 20 mg on line. While more research is needed on the type of exercise needed for depression treatment female cialis 10mg discount, available research indicates that the type of exercise is not as impor- tant as having the physical activity reach a sufficient intensity. For example, both running and weight lifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms [52]. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders [53]. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy [54]. Exercising at 70%90% of maximum heart rate for 20 minutes three times a week has been shown to significantly reduce anxiety sensitivity [55]. Self- reported fears of anxiety sensations, fears of respiratory and cardiovascular symp- toms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program [56]. In a study by Cox and colleagues [57], the most substantial decrease in state anxiety occurred 90 minutes fol- lowing 20 minutes of aerobic exercise at 80% of maximal oxygen uptake. While useful in treatment, exercise has not been shown to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo [58]. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier. In general, exercise does appear to be effective in reducing symptoms asso- ciated with anxiety (see Table 3). Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise. The most common risk of physical activity in adults is musculo- skeletal injury [60, 61]. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports [18]. Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. Prevalence of anxiety, depression, and substance use disorders in an urban general medicine practice. Generalized anxiety and depression in primary care: prevalence, recognition, and management. Panic disorder in the primary care setting: Comorbidity, disability, service utilization, and treatment. Posttraumatic stress disorder in primary care: Prevalence and relationships with physical symptoms and medical utilization. Prevalence of posttraumatic stress disorder in Veterans Affairs primary care clinics. Current trends in the assessment and somatic treatment of resistant/refractory major depression: An overview. Practice Guideline for the Treatment of Patients with Major Depressive Disorder (2nd ed. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease. Common mood and anxiety states: Gender differences in the protective effect of physical activity. Individual difference, exercise and leisure activity in predicting affective and well-being in young adults. Womens college physical activity and self-reports of physician-diagnosed depression and of current symptoms of psychological distress. Association between physical activity and mental disorders among adults in the United States. Inverse association between physical inactivity and mental health in men and women. Effect of the physical activities in leisure time and commuting to work on mental health. The relationship between physical activity and mental health in a national sample of college females. Relationship of vigorous physical activity to psychologic distress among adolescents. Exercise in prevention and treatment of anxiety and depression among children and young people. Physical activity and mental well-being in older people participating in the Better Ageing Project. The antidepressant effect of running is associated with increased hippocampal cell proliferation. Depression duration but not age predicts hippocampal volume loss in medically healthy women with recurrent major depression. Adaptation of the hypothalamo- pituitary adrenal axis to chronic exercise stress in humans. Effects of running or weight lifting on self-concept in clinically depressed women. Clinical prac- tice guidelines for the management of depression in primary care [monograph on the Intranet]. Effects of exercise on depressive symptoms in older adults with poorly responsive depressive disorder. A randomized controlled trial of high versus low intensity weight training versus general practitioner care for clinical depression in older adults. Effects of physical exercise on anxiety, depression, and sensitivity to stress: A unifying theory. Comparison of aerobic exercise, clomipramine, and placebo in the treatment of panic disorder. Physical activity and public health: A recommendation for the Centers for Disease Control and Prevention and the American College of Sports Medicine. A case-control study to investigate the relation between low and moderate levels of physical activity and osteoarthritis of the knee using data collected as part of the Allied Dunbar National Fitness Survey. Epidemiology of musculoskeletal injuries among sedentary and physically active adults. Couple Therapy for Depression 12 Couple Therapy for Depression 12 These symptoms often come with feelings Not all therapies are effective for everyone of guilt, worthlessness and low self- as some people suit some approaches Counselling for Depression 14 Counselling for Depression 14 better than others and some approaches esteem, along with loss of condence and feelings of helplessness. It aims to give you the community and whatever your religion or information you need, help you ask the values, so long as you are willing to give right questions and decide which therapy them a try.

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The position of the upper arm is xed at the shoulder by the action of the shoulder muscles generic female cialis 20mg overnight delivery. We will calculate buy cheap female cialis online, under the conditions of equilibrium buy 10 mg female cialis overnight delivery, the pulling force Fm exerted by the biceps muscle and the direction and magnitude of the reaction force Fr at the fulcrum (the joint). The calculations will be performed by con- sidering the arm position as a Class 3 lever, as shown in Fig. The angle of the muscle force can be calculated from trigonometric con- siderations, without recourse to the conditions of equilibrium. For equilibrium, the sum of the x and y components of the forces must each be zero. The additional necessary equation is obtained from the torque con- ditions for equilibrium. There are two torques about this point: a clockwise torque due to the weight and a counterclockwise torque due to the vertical y component of the muscle force. Since the reaction force Fr acts at the fulcrum, it does not produce a torque about this point. Assuming as before that the weight supported is 14 kg, these equations become 1440 cos 72. In these calculations we have omitted the weight of the arm itself, but this eect is considered in Exercise 1-8. Our calculations show that the forces exerted on the joint and by the muscle are large. In fact, the force exerted by the muscle is much greater than the weight it holds up. They all apply forces by means of levers that have a mechanical advantage less than one. A small change in the length of the muscle produces a relatively larger displacement of the limb extremities (see Exercise 1-10). Of course, this is also the speed of his hand at the point where he releases the ball. The hip is stabilized in its socket by a group of muscles, which is represented in Fig. When a person stands erect, the angle of this force is about 71 m with respect to the horizon. The force W acting on the bottom of the lever is the reaction force of the ground on the foot of the person. As a result, the center of gravity of the body shifts into a position more directly above the hip joint, decreasing the force on the injured area. This is a signicant reduction from the forces applied during a normal one-legged stance. We will analyze the forces involved when the trunk is bent at 60 from the vertical with the arms hanging freely. The weight of the trunk W1 is uniformly distributed along the back; its eect can be represented by a weight suspended in the middle. The weight of the head and arms is represented by W2 suspended at the end of the lever arm. The erector spinalis muscle, shown as the connection D-C attached at a point two-thirds up the spine, maintains the position of the back. For a 70-kg man, W and W 1 2 are typically 320 N (72 lb) and 160 N (36 lb), respectively. It is evident too that the position shown in the gure is not the recom- mended way of lifting a weight. The balancing force is provided by the muscle connected to the heel by the Achilles tendon. Calculations show that while standing tiptoe on one foot the compressional force on the tibia is 3. In fact, the human body (and bodies of all animals) is a dynamic system continually responding to stimuli generated internally and by the external environment. Because the center of gravity while standing erect is about half the height above the soles of the feet, even a slight displacement tends to topple the body. As has been demonstrated experimentally the simple act of standing upright requires the body to be in a continual back and forth, left right, swaying motion to maintain the center of gravity over the base of support. To compensate for the shifting center of gravity this center of pressure is continually shifting by several cen- timeters over the area of the soles of the feet on a time scale of about half a second. Small back-and-forth perturbations of the center of mass (displace- ments less than about 1. Hip movements are required to compensate for larger displacements as well as for left right perturbations. The maintaining of balance in the process of walking requires a yet more complex series of compensating movements as the support for the center of gravity shifts from one foot to the other. The performance of this task is most remarkable when accidentally we slip and the center of gravity is momentar- ily displaced from the base of support. During this short time interval, the whole mus- cular system is called into action by the righting reex to mobilize various parts of the body into motion so as to shift the center of mass back over the base of support. The nervous system obtains information required to maintain balance prin- cipally from three sources: vision, the vestibular system situated in the inner ear that monitors movement and position of the head, and somatosensory sys- tem that monitors position and orientation of the various parts of the body. With age, the eciency of the functions required to keep a person upright decreases resulting in an increasing number of injuries due to falls. In the United States, the number of accidental deaths per capita due to falls for persons above the age of 80 is about 60 times higher than for people below the age of 70. Another aspect of the body dynamics is the interconnectedness of the musculoskeletal system. Through one path or another, all muscles and bones are connected to one another, and a change in muscle tension or limb posi- tion in one part of the body must be accompanied by a compensating change elsewhere. The bones act as the tent poles and the muscles as the ropes bringing into and balancing the body in the desired posture. The proper functioning of this type of a structure requires that the forces be appropriately distributed over all the bones and muscles. For example, excessive tightness, perhaps through overexertion, of the large muscles at the front of our legs will tend to pull the torso forward. To compensate for this forward pull, the muscles in the back must also tighten, often exerting excess force on the more delicate structures of the lower back. In this way, excess tension in one set of muscles may be reected as pain in an entirely dierent part of the body. Assume the person does not slide and the weight of the person is equally distributed on both feet. Using the data provided in the text, calculate the maximum weight that the arm can support in the position shown in Fig. Calculate the force applied by the biceps and the reaction force (Fr) at the joint as a result of a 14-kg weight held in hand when the elbow is at (a) 160 and (b) 60. Note that under these conditions the lower part of the arm is no longer horizontal.