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Cardizem

Geetha Jayaram, M.B.B.S., M.D.

  • Co-Director, Short Stay Unit
  • Professor of Psychiatry and Behavioral Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0004486/geetha-jayaram

So heart attack in the style of demi lovato ameritz top tracks cheap cardizem 120mg on-line, too blood pressure medications with the least side effects best 60 mg cardizem, the instinct of love arterial insufficiency cardizem 60 mg with visa, when it is directed towards an object hypertension nursing assessment order discount cardizem line, stands in need of some contribution from the instinct for mastery if it is in any way to obtain possession of that object heart attack jaw pain generic cardizem 180mg online. The difficulty of isolating the two classes of instinct in their actual manifestations is indeed what has so long prevented us from recognizing them arrhythmia consultants of greater washington 180mg cardizem visa. It is very rarely that an action is the work of a single instinctual impulse (which must in itself be compounded of Eros and destructiveness). In order to make an action possible there must be as a rule a combination of such compounded motives. Lichtenberg who taught physics at Gottingen during our classical age though perhaps he was even more remarkable as a psychologist than as a physicist. A lust for aggression and destruction is certainly among them: the countless cruelties in history and in our everyday lives vouch for its existence and its strength. The satisfaction of these destructive impulses is of course facilitated by their admixture with others of an erotic and idealistic kind. When we read of the atrocities of the past, it sometimes seems as though the idealistic motives served only as an excuse for the destructive appetites; and sometimes in the case, for instance, of the cruelties of the Inquisition it seems as though the idealistic motives had pushed themselves forward in consciousness, while the destructive ones lent them an unconscious reinforcement. Nevertheless I should like to linger for a moment over our destructive instinct, whose popularity is by no means equal to its importance. As a result of a little speculation, we have come to suppose that this instinct is at work in every living creature and is striving to bring it to ruin and to reduce life to its original condition of inanimate matter. Thus it quite seriously deserves to be called a death instinct, while the erotic instincts represent the effort to live. The death instinct turns into the destructive instinct when, with the help of special organs, it is directed outwards, on to objects. Some portion of the death instinct, however, remains operative within the organism, and we have sought to trace quite a number of normal and pathological phenomena to this internalization of the destructive instinct. We have even been guilty of the heresy of attributing the origin of conscience to this diversion inwards of aggressiveness. You will notice that it is by no means a trivial matter if this process is carried too far: it is positively unhealthy. On the other hand if these forces are turned to destruction in the external world, the organism will be relieved and the effect must be beneficial. This would serve as a biological justification for all the ugly and dangerous impulses against which we are struggling. It must be admitted that they stand nearer to Nature than does our resistance to them for which an explanation also needs to be found. It may perhaps seem to you as though our theories are a kind of mythology and, in the present case, not even an agreeable one. We are told that in certain happy regions of the earth, where nature provides in abundance everything that man requires, there are races whose life is passed in tranquillity and who know neither coercion nor aggression. I can scarcely believe it and I should be glad to hear more of these fortunate beings. The Russian Communists, too, hope to be able to cause human aggressiveness to disappear by guaranteeing the satisfaction of all material needs and by establishing equality in other respects among all the members of the community. They themselves are armed to-day with the most scrupulous care and not the least important of the methods by which they keep their supporters together is hatred of everyone beyond their frontiers. In any case, as you yourself have remarked, there is no question of getting rid entirely of human aggressive impulses; it is enough to try to divert them to such an extent that they need not find expression in war. If willingness to engage in war is an effect of the destructive instinct, the most obvious plan will be to bring Eros, its antagonist, into play against it. Anything that encourages the growth of emotional ties between men must operate against war. In the first place they may be relations resembling those towards a loved object, though without having a sexual aim. Whatever leads men to share important interests produces this community of feeling, these identifications. A complaint which you make about the abuse of authority brings me to another suggestion for the indirect combating of the propensity to war. One instance of the innate and ineradicable inequality of men is their tendency to fall into the two classes of leaders and followers. The latter constitute the vast majority; they stand in need of an authority which will make decisions for them and to which they for the most part offer an unqualified submission. This suggests that more care should be taken than hitherto to educate an upper stratum of men with independent minds, not open to intimidation and eager in the pursuit of truth, whose business it would be to give direction to the dependent masses. It goes without saying that the encroachments made by the executive power of the State and the prohibition laid by the Church upon freedom of thought are far from propitious for the production of a class of this kind. The ideal condition of things would of course be a community of men who had subordinated their instinctual life to the dictatorship of reason. Nothing else could unite men so completely and so tenaciously, even if there were no emotional ties between them. No doubt the other indirect methods of preventing war are more practicable, though they promise no rapid success. It is a better plan to devote oneself in every particular case to meeting the danger with whatever means lie to hand. I should like, however, to discuss one more question, which you do not mention in your letter but which specially interests me. After all, it seems to be quite a natural thing, to have a good biological basis and in practice to be scarcely avoidable. For the purpose of an investigation such as this, one may perhaps be allowed to wear a mask of assumed detachment. The answer to my question will be that we react to war in this way because everyone has a right to his own life, because war puts an end to human lives that are full of hope, because it brings individual men into humiliating situations, because it compels them against their will to murder other men, and because it destroys precious material objects which have been produced by the labours of humanity. Other reasons besides might be given, such as that in its present-day form war is no longer an opportunity for achieving the old ideals of heroism and that owing to the perfection of instruments of destruction a future war might involve the extermination of one or perhaps both of the antagonists. All this is true, and so incontestably true that one can only feel astonished that the waging of war has not yet been unanimously repudiated. It may be questioned whether a community ought not to have a right to dispose of individual lives; every war is not open to condemnation to an equal degree; so long as there exist countries and nations that are prepared for the ruthless destruction of others, those others must be armed for war. But I will not linger over any of these issues; they are not what you want to discuss with me, and I have something different in mind. It is my opinion that the main reason why we rebel against war is that we cannot help doing so. For incalculable ages mankind has been passing through a process of evolution of culture. Though its causes and beginnings are obscure and its outcome uncertain, some of its characteristics are easy to perceive. It may perhaps be leading to the extinction of the human race, for in more than one way it impairs the sexual function; uncultivated races and backward strata of the population are already multiplying more rapidly than highly cultivated ones. The process is perhaps comparable to the domestication of certain species of animals and it is undoubtedly accompanied by physical alterations; but we are still unfamiliar with the notion that the evolution of civilization is an organic process of this kind. The psychical modifications that go along with the process of civilization are striking and unambiguous. They consist in a progressive displacement of instinctual aims and a restriction of instinctual impulses. Sensations which were pleasurable to our ancestors have become indifferent or even intolerable to ourselves; there are organic grounds for the changes in our ethical and aesthetic ideals. Of the psychological characteristics of civilization two appear to be the most important: a strengthening of the intellect, which is beginning to govern instinctual life, and an internalization of the aggressive impulses, with all its consequent advantages and perils. Now war is in the crassest opposition to the psychical attitude imposed on us by the process of civilization, and for that reason we are bound to rebel against it; we simply cannot any longer put up with it. This is not merely an intellectual and emotional repudiation; we pacifists have a constitutional intolerance of war, an idiosyncrasy magnified, as it were, to the highest degree. It seems, indeed, as though the lowering of aesthetic standards in war plays a scarcely smaller part in our rebellion than do its cruelties. But it may not be Utopian to hope that these two factors, the cultural attitude and the justified dread of the consequences of a future war, may result within a measurable time in putting an end to the waging of war. But one thing we can say: whatever fosters the growth of civilization works at the same time against war. This work was the product of the labours of four or five years and its origin was unusual. The ordinary methods of treatment clearly offered little or no help: other paths must be followed. And how was it by any means possible to give patients help when one understood nothing of their illness, nothing of the causes of their sufferings or of the meaning of their complaintsfi So I eagerly sought direction and instruction from the great Charcot in Paris and from Bernheim at Nancy; finally, an observation made by my teacher and friend, Josef Breuer of Vienna, seemed to open a new prospect for understanding and therapeutic success. For these new experiments made it a certainty that the patients whom we described as neurotic were in some sense suffering from mental disturbances and ought therefore to be treated by psychological methods. The psychology which ruled at that time in the academic schools of philosophy had very little to offer and nothing at all for our purposes: we had to discover from the start both our methods and the theoretical hypotheses behind them. So I worked in this direction, first in collaboration with Breuer and afterwards independently of him. In the end I made it a part of my technique to require my patients to tell me without criticism whatever occurred to their minds, even if they were ideas which did not seem to make sense or which it was distressing to report. My Contact With Josef Popper-Lynkeus 4808 When they fell in with my instructions they told me their dreams, amongst other things, as though they were of the same kind as their other thoughts. This was a plain hint that I should assign as much importance to these dreams as to other, intelligible, phenomena. They, however, were not intelligible, but strange, confused, absurd: like dreams, in fact which for that very reason, were condemned by science as random and senseless twitchings of the organ of the mind. But by applying to these dreams, and more particularly to my own dreams, the procedure which I had already used for the study of other abnormal psychological structures, I succeeded in answering most of the questions which could be raised by an interpretation of dreams. What is the origin of all the strange characteristics which distinguish dreams from waking lifefi Some of the answers were easily given and turned out to confirm views that had already been put forward; but others involved completely new hypotheses with regard to the structure and functioning of the apparatus of the mind. People dream about the things that have engaged their minds during the waking day. People dream in order to allay impulses that seek to disturb sleep, and in order to be able to sleep on. But why was it possible for dreams to present such a strange appearance, so confusedly senseless, so obviously contrasted with the content of waking thought, in spite of being concerned with the same materialfi There could be no doubt that dreams were only a substitute for a rational process of thought and could be interpreted that is to say, translated into a rational process. But what needed explaining was the fact of the distortion which the dream-work had carried out upon the rational and intelligible material. My Contact With Josef Popper-Lynkeus 4809 Dream-distortion was the profoundest and most difficult problem of dream life. And light was thrown on it by the following consideration, which placed dreams in a class along with other psychopathological formations and revealed them, as it were, as the normal psychoses of human beings. For our mind, that precious instrument by whose means we maintain ourselves in life, is no peacefully self-contained unity. It is rather to be compared with a modern State in which a mob, eager for enjoyment and destruction, has to be held down forcibly by a prudent superior class. The whole flux of our mental life and everything that finds expression in our thoughts are derivations and representatives of the multifarious instincts that are innate in our physical constitution. But these instincts are not all equally susceptible to direction and education, or equally ready to fall in with the demands of the external world and of human society. A number of them have retained their primitive, ungovernable nature; if we let them have their way, they would infallibly bring us to ruin. Consequently, learning by experience, we have developed organizations in our mind which, in the form of inhibitions, set themselves up against the direct manifestations of the instincts. Every impulse in the nature of a wish that arises from the sources of instinctual energy must submit itself to examination by the highest agencies of our mind, and, if it is not approved, is rejected and restrained from exercising any influence upon our movements that is, from coming into execution. Often enough, indeed, such wishes are even forbidden to enter consciousness, which is habitually unaware even of the existence of these dangerous instinctual sources. We describe such impulses as being repressed from the point of view of consciousness, and as surviving only in the unconscious. If what is repressed contrives somehow to force its way into consciousness or into movement or into both, we are no longer normal: at that point the whole range of neurotic and psychotic symptoms arise. The maintenance of the necessary inhibitions and repressions imposes upon our mind a great expenditure of energy, from which it is glad to be relieved. A good opportunity for this seems to be offered at night by the state of sleep, since sleep involves a cessation of our motor functions.

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Health care teams and licensing agencies should anticipate preparing for diverse driving capacity scenarios in the years to come blood pressure chart jnc purchase cardizem 60 mg with mastercard. Such recommendations should be based on the most current scientific data and implemented in an efficient review process blood pressure numbers what do they mean order cardizem 180mg with amex. Increased Public Awareness of Medication Adverse Effects that May Impair Driving Many prescription and over-the-counter medications have the potential to impair driver performance pulse pressure sites purchase cardizem 60mg visa. Despite warnings on the label and counseling by clinicians arterial blood gas test cheap 180mg cardizem with amex, many older adults and their caregivers are unaware of these risks arrhythmia medications order 180mg cardizem visa. This meeting hosted presentations of epidemiologic and controlled data on the effects of sedating drugs and crash risk blood pressure z score discount cardizem, as well as presentations from innovators of devices designed to test the degree to which drugs may impair driving. Efforts to increase older adult driver, caregiver, and clinician education and to clarify labeling for consumers are encouraged. Currently, manufacturers of medications do not routinely test their products for effects on driving, nor are they required to do so. The identification and routine use of effective testing parameters to identify medications that may interfere with the ability to safely operate a motor vehicle is encouraged. Similarly, such parameters could be used to identify medications that do not typically impair drivers when used as directed. Promotion of Self-Awareness and Appropriate Self-Regulation Generally, older adult drivers modify their driving routine by self-regulation. Some drivers participate in educational programs or occupational therapy interventions in an effort to 196 decrease crash risk by increasing their awareness of questionable driving habits and learning adaptive strategies. Occupational therapy interventions assist older adult drivers to develop 21 objectivity in themselves and their driving environment. In late life, both women and men do compensate for individual changes in their health and capacity to drive, but a recent study found that older women were somewhat more likely than older men to stop or limit driving 22 over time and that the factors associated with these changes differed by gender. Older adults are also less able to endure and recover from injuries sustained in an automobile crash. Vehicle manufacturers are encouraged to explore and implement enhancements in vehicle design that address and compensate for these physiologic changes. In particular, vehicle designs based on the anthropometric parameters of older adults. Improvements in headlamp lighting to enhance nighttime visibility and reduce glare, as well as the use of high-contrast legible fonts and symbols for in- 23 vehicle displays, may help compensate for age-related changes in vision. In addition, 24 prominent analog gauges may be easier to see and interpret than small digital devices. Computers have revolutionized the motor vehicle industry by managing airbag safety systems, antilock brakes, and global positioning systems. In-vehicle tools to assess for high-risk conditions may be developed in the future. In the event of a crash, improved crashworthy vehicle designs and restraint systems designed for fragile occupants may enhance the safety of older adult drivers and passengers. Certain add-on features may also make current vehicle designs safer and more accessible for older adult drivers. For example, handholds and supports on door frames may facilitate entry/exit for both drivers and passengers. Padded steering wheels and seat adjuster handles (rather than knobs) may benefit drivers with decreased hand grip, and adjustable steering wheels and foot pedals may aid drivers with limited range of motion or 25 of smaller stature. Crashes involving older adult drivers and fatality rates have fallen in recent years, despite the increased fragility of older adults. A initial effort to promote the selection of vehicles that may be a better fit for older adults is in place at the American Automobile 27 Association website. Other adjustable controls and displays may allow older drivers to tailor their vehicle to their changing abilities and needs. Safety features that may benefit 197 older adults include smart headlights, emergency response systems, reverse monitoring, blind spot/lane departure warning, stability control, assisted parking, voice-activated 28 controls, crash mitigation systems, and drowsy driver alerts. Electronic stability control is now standard equipment on all new vehicles and may lead to further safety gains as it 29 becomes more prevalent in the vehicle fleet. Optimal Environments for Older Adult Drivers and Pedestrians To promote aging in place, clinical teams are encouraged to be realistic regarding environmental features essential for older adults. A recent review noted that older adults prioritized safety considerations when making mobility choices. Many older adult drivers are at a disadvantage on roads and highways that are most heavily used by and traditionally designed for a younger population. In a telephone survey of 2,422 people 50 and older, nearly one of five participants considered inconsiderate drivers to be a major problem. Other commonly identified problems included traffic congestion, crime, and 31 fast traffic. These problems may be ameliorated through traffic law enforcement and better road and traffic control designs. One of the top requests of the nearly 200 Iowans (older drivers, transportation professionals, and senior-related professionals) attending the Iowa Older Drivers 32 Forum was the enhanced enforcement of speed and aggressive driving laws. In terms of road and traffic engineering, the Federal Highway Administration has recognized and addressed the needs of older adult drivers in its Handbook for Designing Roadways for the Aging Population, a supplement to existing standards and guidelines in the areas of highway geometry, operations, 33 and traffic control devices. The Federal Highway Administration handbook is updated periodically to incorporate the latest research on the effectiveness of design and engineering enhancement to accommodate older adult drivers. Better Alternatives to Driving Alternatives to driving are often less than ideal or nonexistent. When faced with the choice of unsafe driving or losing mobility, many older adults risk their safety by continuing to drive. Existing forms of transportation clearly need to be optimized for use by older adults. In a telephone survey of 2,422 people 50 and older, ride-sharing was the second most common mode of transportation (after driving); however, nearly a quarter of the survey participants cited feelings of dependency and concerns about imposing as a barrier to use. Public 198 transportation was the usual mode of transportation for fewer than 5% of survey participants, with many citing unavailable destinations, problems with accessibility, and fear of crime as barriers to use. Fewer than 5% used taxis as their usual mode of transportation because of the 31 high cost. Until these barriers are addressed, these forms of transportation will remain suboptimal for many older adults. Transportation programs created specifically for the older population, such as senior shuttles and vans, exist in certain communities. A number of locations have adopted the independent 34 transportation network model. The occupational therapy discipline has been at the forefront of driving and community mobility issues. Its work reminds the clinical team to maintain a client-centered approach when counseling older adult drivers and to avoid the one-size-fits-all perspective. Most clinical team members and especially occupational therapists agree that often no single element of physical and cognitive capacity is sufficient to require driving cessation, but rather a multidimensional 36 approach is necessary. The number of different fitness-to-drive assessment tools and simulator evaluation techniques reflect the heterogeneity of the older adults these strategies are designed to assess. Society as a whole needs to be involved in a discussion of acceptable thresholds of risk. In the process of identifying drivers potentially at increased risk of driving safety difficulties, a fair and appropriate assessment of risk is needed, identifying factors potentially influencing risk, considering interventions to lower risk, and identifying ways to facilitate the transition to driving limitations or cessation if drivers prefer to do so or if interventions are not possible or successful. More communication and coordination among the parties involved is needed, as well as demonstrating the effectiveness of different steps in the process, and more information on feasibility and sustainability. A holistic approach to the 37 process is needed that considers not just driving, but mobility in a broad sense. Interventions have been developed that enhance relevant functional abilities, driver awareness of deficits, clinician and caregiver awareness of 38-47 how to address the issue, and facilitating the transition to driving cessation. Many of these studies have been preliminary or small scale, and much more information is needed on how to broaden their applicability and to determine the ancillary effects if they are applied more broadly. Although these and other questions need to be answered, the good news is that much more preliminary information is available now than at any time in the past. Consequently, it is realistic to think holistically of a more comprehensive and integrated approach to driving safety and mobility that better balances individual autonomy, mobility, and safety with public health and safety. This holistic approach reflects many current national, State, and local efforts that more broadly consider the interrelationship and integration of transportation, health, housing, and environmental factors. Examples of such initiatives include the Interagency Partnership for Sustainable Communities by the Department of Transportation, the Environmental Protection Agency, and Housing and Urban Development. Other initiatives, such as the Ride to Wellness Program, directly address the link between transportation and health factors. Programs such as these are to be encouraged and studied, with the goal of enhancing and optimizing their effectiveness, efficiency, and sustainability. The trail making test as a screening instrument for driving performance in older drivers; a translational research. Family reports of medically impaired drivers in Missouri: cognitive concerns and licensing outcomes. Knowledge, attitudes, and practices of geriatricians regarding patients with dementia who are potentially dangerous automobile drivers: a national survey. Maximizing Human Potential: Newsletter of the Network on Environments, Services and Technologies for Maximizing Independence. Automobile driving in older adults: factors affecting driving restriction in men and women. High-priority research and development needs for maintaining the safety and mobility of older drivers. Comparison of novice and experienced pilots using analog and digital flight displays. Trends in older driver crash involvement rates and survivability in the United States: an update. The effectiveness of electronic stability control in reducing real-world crashes: a literature review. How design of places promotes or inhibits mobility of older adults: realist synthesis of 20 years of research. Assessment tools predicting fitness to drive in older adults: a systematic review. The efficacy of an educational intervention in promoting self-regulation among high risk-older drivers. Speed-of- processing and driving simulator training result in improved driving performance. A randomized trial of a physical conditioning program to enhance the driving performance of older persons. At the crossroads: development and evaluation of a dementia caregiver group intervention to assist in driving cessation. The American Medical Association Older Driver Curriculum for health professionals: changes in trainee confidence, attitudes, and practice behavior. The services described in this Guide will most often fall under Evaluation and Management (E/M) services. If you choose to apply codes from the Preventive Medicine services category, consult Table 1 for the appropriate codes. If any additional services are provided over and above the E/M services, codes from Table 2 may be additionally applied. These codes can be used for a complete Preventive Medicine history and physical examination for a new patient (or one who has not been seen in 3 or more years), which may include assessment and counseling on driver safety. If significant driver assessment and counseling take place at the time of an office or outpatient service (99201-99215), Modifier-25 may be added to the codes above. Note: Codes from the Preventive Medicine Services 99386-99387 and 99396-99397 can be reported only once per year.

When vibration seems more intact than it should pulse pressure 30 discount cardizem 120mg otc, ask the patient where he feels the sensation zartan blood pressure medication discount cardizem 120mg with mastercard. It is also closely related to position sense and is mediated via the posterior columns pulse pressure ejection fraction cheap cardizem 120mg line. Pressure sense is tested by a firm touch on the skin or by pressure on deep structures (muscle masses pulse pressure fitness discount cardizem on line, tendons pulse pressure hypovolemia order cardizem 60 mg mastercard, nerves) hypertension treatment purchase cheap cardizem line, using finger pressure or a blunt object. Deep pain may be tested by squeezing muscles, tendons, or the testicles; by pressing on superficial nerves or on the eyeballs; or by pushing a finger interphalangeal joint into extreme, forced hyperflexion. Firm pressure on the base of a nail with a hammer or tuning fork handle also hurts a great deal. The response to superficial or deep pain stimulation may be simply delayed before it is lost. Clinical versus quantitative vibration assessment: improving clinical performance. Enumerating Meissner corpuscles: future gold standard of large fiber sensorimotor polyneuropathyfi Normative values of vibratory perception in 530 children, juveniles and adults aged 3-79 years. Sensory effects in man of lesions of the posterior columns and of some other afferent pathways. Position and vibration sensations: functions of the dorsal spinocerebellar tractsfi Proprioception and vibration sensibility discrimination in the absence of the posterior columns. Pthomegroup C H A P T E R 34 the Interoceptive, or Visceral, Sensations Interoceptive sensations are general visceral sensations that arise from the internal organs. The special visceral sensations (smell and taste) are discussed with the cranial nerves. Cell bodies are in the dorsal root and associated cranial ganglia; impulses enter the central nervous system through the posterior roots and ascend to higher centers through pathways close to those that carry general somatic afferent impulses. Visceral afferent fibers are involved with unconscious visceral and autonomic reflexes and also likely convey visceral sensations such as hunger, nausea, sexual excitement, vesical distention, and visceral pain. Afferent impulses from the viscera may reach consciousness by a variety of routes. Some synapse in the dorsal horn, and axons of the next-order neurons cross to the opposite spinothalamic tract, where the fibers that carry visceral pain lie medial to those that carry superficial pain and temperature sensations. Many ascend for a great distance in Lissauer tract before synapsing, and some ascend by long intersegmental fibers in the white matter at the border of the dorsal horn, reaching the hypothalamus and thalamus without decussating. As a consequence of the multiple pathways and redundancy, localization of visceral pain is not precise. The gyms rectus, rather than the parietal cortex, may be the end station for visceral afferent sensation. In the history, symptoms related to visceral function and conveyed by visceral afferent fibers include such things as gastric fullness and early satiety, gastric discomfort, intestinal spasm, a pressure sensation in the chest, a sensation of fullness in the bladder or rectum, a desire for micturition, a sense of engorgement from the genitalia, or pain in the internal organs. The viscera are generally insensitive to the usual stimuli that cause pain, but spasm, inflammation, trauma, pressure, distention, or tension on the viscera may produce severe pain, some of which results from involvement of the surrounding tissues. Pain endings are found in the parietal pleura over the thoracic wall and the diaphragm, although probably none are present in the visceral pleura or the lungs. The parietal peritoneum is sensitive, especially to distention, but the visceral peritoneum is probably not sensitive. Visceral pain is often vaguely localized or diffuse and likely to be described by the patient as deep- seated. In addition to the pain experienced in the viscus itself, there may be pain referred to other areas, and the area where the referred pain is felt may be hyperalgesic to stimulation. The convergence on somatic and visceral sensation on the same neuronal population may be one explanation for referred pain. The zones of referred pain and hyperalgesia found in disease of the various viscera are rather poorly localized and vary widely. Referred pain may be felt in the dermatome or skin segment directly over the involved organ as a result of corresponding segmental innervation in the area of cutaneous distribution of the spinal nerves that correspond to the segmentalPthomegroup spinal cord level that supplies the viscus, or the pain may be quite distant from the diseased area, as a result of shifting of the viscus during embryonic development. Appendiceal pain is felt directly over the appendix; the pain of angina pectoris may radiate down the left arm; and renal pain is referred to the groin. As a consequence, in disease of the gallbladder, liver, or central portion of the diaphragm, there may be pain and hyperesthesia not only in the viscus involved but also on the side of the neck and shoulder in the C3-C5 cutaneous distribution or in the area supplied by the posterior roots of those nerves whose anterior roots supply the diaphragm. Other areas of referred visceral pain include midthoracic levels for stomach, duodenum, pancreas, liver, and spleen; upper thoracic levels for the heart; upper and midthoracic levels for the lungs; and low thoracic and upper lumbar levels for the kidney. With some exceptions, the referred pain appears on the same side of the body in which the diseased organ is located. The anatomy of the pain pathways influences the techniques for surgical management of chronic visceral pain. Because the visceral afferent fibers lie medial in the spinothalamic tracts, a cordotomy to control visceral pain must be carried out with a deeper incision than one for the relief of somatic pain. Also, because the afferent impulses from the viscera ascend for a greater distance before decussating, it must be done at a higher level. Because visceral pain may be carried in both crossed and uncrossed pathways, a cordotomy to control visceral pain may have to be bilateral. Visceral sensation, although clinically important, cannot be adequately evaluated by the routine neurologic examination. There are special techniques that may give some information, such as tests for the appreciation of the sensations of distention, pain, heat, and cold in the bladder during cystometric examination. Pthomegroup C H A P T E R 35 Cerebral Sensory Functions Cerebral sensory functions are those that involve the primary sensory areas of the cortex to perceive the stimulus and the sensory association areas to interpret the meaning of the stimulus and place it in context. The term combined sensation describes perception that involves integration of information from more than one of the primary modalities for the recognition of the stimulus. The parietal lobe functions to analyze and synthesize the individual varieties of sensation and to correlate the perception of the stimulus with memory of past stimuli that were identical or similar and with knowledge about related stimuli to interpret the stimulus and aid in discrimination and recognition. The parietal cortex receives, correlates, synthesizes, and refines the primary sensory information. It is not concerned with the cruder sensations, such as recognition of pain and temperature, which are subserved by the thalamus. The cortex is important in the discrimination of the finer or more critical grades of sensation, such as the recognition of intensity, the appreciation of similarities and differences, and the evaluation of the gnostic, or perceiving and recognizing, aspects of sensation. It is also important in localization, in the recognition of spatial relationships and postural sense, in the appreciation of passive movement, and in the recognition of differences in form and weight and of two-dimensional qualities. These elements of sensation are more than simple perceptions, and their recognition requires integration of the various stimuli into concrete concepts as well as calling forth engrams. Cortical sensory functions are perceptual and discriminative rather than the simple appreciation of information from the stimulation of primary sensory nerve endings. The cortical modalities of greatest clinical relevance include stereognosis, graphesthesia, two-point discrimination, sensory attention, and other gnostic or recognition functions. The loss of these varieties of combined sensation may be considered a variety of agnosia, or the loss of the power to recognize the meaning of sensory stimuli. The primary modalities must be relatively preserved before concluding that a deficit in combined sensation is due to a parietal lobe lesion. Only when the primary sensory modalities are normal can the unilateral failure to identify an object by feel be termed astereognosis and be attributed to a central nervous system lesion. Impairment of primary modalities too slight to account for the recognition difficulty can also properly be termed astereognosis; making this judgment requires experience. Stereognosis is the perception, understanding, recognition, and identification of the form and nature of objects by touch. Astereognosis can be diagnosed only if cutaneous and proprioceptive sensations are intact; if these are significantly impaired, the primary impulses cannot reach consciousness for interpretation. First, the size is perceived, followed by appreciation of shape in two dimensions, form in three dimensions, and finally identification of the object. Size perception is tested by using objects of the same shape but different sizes, shape perception with objects of simple shape (circle, square, triangle), cut out of stiff paper or plastic, and form perception by using solid geometric objects (cube, pyramid, ball). Finally, recognition is evaluated by having the patient identify only by feel simple objects placed in his hand. For more refinedPthomegroup testing, the patient may be asked to differentiate coins, identify letters carved from wood or fiber-board, or count the number of dots on a domino. It is striking confirmation of the restricted nature of the deficit in pure motor stroke to demonstrate exquisitely preserved stereognosis in a paralyzed hand. When stereognosis is impaired, there may be a delay in identification or a decrease in the normal exploring movements as the patient manipulates the unknown object. Stereognosis testing normally compares the two hands, and any deficit will be unilateral. Inability to recognize objects by feel with either hand, if the primary modalities are intact, is tactile agnosia. Recognition of texture is a related type of combined sensation in which the patient tries to recognize similarities and differences between objects of varying textures, such as cotton, silk, wool, wood, glass, and metal. Astereognosis is usually accompanied by agraphesthesia and other cortical deficits; it may occur in isolation as the earliest sign of parietal lobe dysfunction. Graphesthesia (traced figure discrimination, number writing) is the ability to recognize letters or numbers written on the skin with a pencil, dull pin, or similar object. Letters or numbers about 1 cm in height are written on the finger pads, larger elsewhere. A related function is the ability to tell the direction of movement of a light scratch stimulus drawn for 2 to 3 cm across the skin (tactile movement sense, directional cutaneous kinesthesia), which may be a sensitive indicator of function of the posterior columns and primary somatosensory cortex. Loss of graphesthesia or the sense of tactile movement with intact peripheral sensation implies a cortical lesion, particularly when the loss is unilateral. Two-point, or spatial, discrimination is the ability to differentiate, with eyes closed, cutaneous stimulation by one point from stimulation by two points. The best instrument for testing is a two-point discriminator designed for the purpose. To test static two-point, the test instrument is held in place for a few seconds on the site to be tested. To test moving two-point on a finger pad, the discriminator would be pulled from the crease of the distal interphalangeal joint toward the tip of the finger over several seconds. Either one-point or two-point stimuli are delivered randomly, and the minimal distance that can be discerned as two points is determined. Then one-and two-point stimuli are varied randomly, bringing the points closer and closer until the patient begins to make errors. The result is taken as the minimum distance between two points that can be consistently felt separately. Normal two-point discrimination is about 1 mm on the tip of the tongue, 2 to 3 mm on the lips, 2 to 4 mm on the fingertips, 4 to 6 mm on the dorsum of the fingers, 8 to 12 mm on the palm, 20 to 30 mm on the back of the hand, and 30 to 40 mm on the dorsum of the foot. Greater separation is necessary for differentiation on the forearm, upper arm, torso, thigh, and leg. For moving two-point, the technique is the same except the instrument is drawn slowly across the test area. Discrimination for twoPthomegroup moving points is slightly better than for two stationary points. Moving two-point tests the rapidly adapting mechanoreceptors and may have some advantages in the management of patients with peripheral nerve injuries. Loss of two-point discrimination with preservation of other discriminatory tactile and proprioceptive sensation may be the most subtle sign of a lesion of the opposite parietal lobe. Loss of two-point discrimination limited to the distribution of a peripheral nerve or root is helpful in diagnosis and management. Two-point discrimination may also be used to demonstrate a sensory level on the trunk in myelopathy. Sensory extinction, inattention, or neglect is loss of the ability to perceive two simultaneous sensory stimuli. It is a test of sensory attentional mechanisms rather than somatosensory function. It may occur in isolation with parietal lobe lesions or in company with other deficits of attention to hemispace with more extensive lesions. At its most extreme, there is inattention to all of contralateral hemispace (anosognosia, Chapter 10). Testing for tactile extinction uses double simultaneous stimuli at homologous sites on the two sides of the body. If using pinprick (with equally sharp pins), the stimulus on the abnormal side may feel blunt compared to the normal side. Extinction can also be done on one side, touching the face and hand simultaneously. In general, the more rostral area is the dominant one; when face and hand are stimulated, there is extinction of the hand percept (the face-hand test). The most subtle abnormality is for a hand stimulus on the normal side to extinguish a face stimulus on the abnormal side, but such testing pushes the limit of usefulness of the technique.

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Syndromes

  • Swelling in the throat - may be severe
  • Sneezing
  • Breathing tube in severe poisonings
  • Endometriosis (usually only done after ultrasound)
  • Kidney
  • Masses and tumors, including cancer
  • Has a seizure
  • Organ transplant

Navigational Note: Tricuspid valve disease Asymptomatic valvular Asymptomatic; moderate Symptomatic; severe Life-threatening Death thickening with or without regurgitation or stenosis by regurgitation or stenosis; consequences; urgent mild valvular regurgitation or imaging symptoms controlled with intervention indicated blood pressure zones cheap cardizem 180 mg without prescription. Navigational Note: Ventricular arrhythmia Asymptomatic blood pressure device order cardizem with paypal, intervention Non-urgent medical Urgent intervention indicated Life-threatening Death not indicated intervention indicated consequences; hemodynamic compromise Definition:A disorder characterized by a dysrhythmia that originates in the ventricles arrhythmia unborn baby purchase cardizem on line amex. Navigational Note: Ventricular tachycardia Non-urgent medical Symptomatic high pulse pressure young age buy cardizem with paypal, urgent Life-threatening Death intervention indicated intervention indicated consequences; hemodynamic compromise Definition:A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates distal to the bundle of His blood pressure chart 18 year old trusted cardizem 180 mg. Navigational Note: Delayed puberty No breast development by No breast development by - age 13 yrs for females; testes age 14 yrs for females; no volume of <3 cc or no Tanner increase in testes volume or Stage 2 development by age no Tanner Stage 2 by age 16 14 heart attack nursing diagnosis cheap 60 mg cardizem otc. Navigational Note: Hyperparathyroidism Mild symptoms; intervention Moderate symptoms; medical - not indicated intervention indicated Definition:A disorder characterized by an increase in production of parathyroid hormone by the parathyroid glands. Navigational Note: Precocious puberty Physical signs of puberty with Physical signs and biochemical - no biochemical markers for markers of puberty for females <8 years and males <9 females <8 years and males <9 years years Definition:A disorder characterized by unusually early development of secondary sexual features; the onset of sexual maturation begins usually before age 8 for girls and before age 9 for boys. Navigational Note: Papilledema Asymptomatic; no visual field Symptomatic; moderate Symptomatic with marked Best corrected visual acuity of deficit decrease in visual acuity (best decrease in visual acuity (best 20/200 or worse in the corrected visual acuity 20/40 corrected visual acuity worse affected eye and better or 3 lines or less than 20/40 or more than 3 decreased vision from known lines of decreased vision from baseline) known baseline, up to 20/200) Definition:A disorder characterized by swelling around the optic disc. Navigational Note: Retinal tear No retinal detachment and No retinal detachment and - treatment not indicated treatment indicated Definition:A disorder characterized by a small laceration of the retina, this occurs when the vitreous separates from the retina. Navigational Note:If retinal detachment is present, grade under Eye disorders: Retinal detachment Retinal vascular disorder Retinal vascular disorder Retinal vascular disorder with - without neovascularization neovascularization Definition:A disorder characterized by pathological retinal blood vessels that adversely affects vision. Navigational Note: Anal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the opening in the anal canal to the perianal skin. Navigational Note: Anal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the anal region. Navigational Note:Synonym: Burping Bloating No change in bowel function Symptomatic, decreased oral - or oral intake intake; change in bowel function Definition:A disorder characterized by subject-reported feeling of uncomfortable fullness of the abdomen. Navigational Note: Chylous ascites Asymptomatic; clinical or Symptomatic; medical Severe symptoms; elective Life-threatening Death diagnostic observations only; intervention indicated. Navigational Note: Colonic fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the large intestine and another organ or anatomic site. Navigational Note: Colonic hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the colon. Navigational Note: Colonic perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by a rupture in the colonic wall. Navigational Note: Dental caries One or more dental caries, Dental caries involving the Dental caries resulting in - not involving the root root pulpitis or periapical abscess or resulting in tooth loss Definition:A disorder characterized by the decay of a tooth, in which it becomes softened, discolored and/or porous. Navigational Note: Duodenal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the duodenum. Navigational Note: Dyspepsia Mild symptoms; intervention Moderate symptoms; medical Severe symptoms; operative - not indicated intervention indicated intervention indicated Definition:A disorder characterized by an uncomfortable, often painful feeling in the stomach, resulting from impaired digestion. Navigational Note: Enterocolitis Asymptomatic; clinical or Abdominal pain; mucus or Severe or persistent Life-threatening Death diagnostic observations only; blood in stool abdominal pain; fever; ileus; consequences; urgent intervention not indicated peritoneal signs intervention indicated Definition:A disorder characterized by inflammation of the small and large intestines. Navigational Note:If reporting a known abnormality of the colon, use Gastrointestinal disorders: Colitis. Navigational Note: Esophageal fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the esophagus and another organ or anatomic site. Navigational Note: Esophageal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the esophagus. Navigational Note: Esophageal varices Self-limited; intervention not Transfusion indicated; Life-threatening Death hemorrhage indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from esophageal varices. Navigational Note: Gastric hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the gastric wall. Navigational Note: Gastric perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition:A disorder characterized by a rupture in the stomach wall. Navigational Note: Gastroesophageal reflux Mild symptoms; intervention Moderate symptoms; medical Severe symptoms; operative - disease not indicated intervention indicated intervention indicated Definition:A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. Navigational Note: Hemorrhoidal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the hemorrhoids. Navigational Note: Ileal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the ileal wall. Navigational Note: Ileal perforation Invasive intervention not Invasive intervention Life-threatening Death indicated indicated consequences; urgent operative intervention indicated Definition:A disorder characterized by a rupture in the ileal wall. Navigational Note: Jejunal hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the jejunal wall. Navigational Note: Oral hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the mouth. Navigational Note: Pancreatic hemorrhage Mild symptoms; intervention Moderate symptoms; Transfusion indicated; Life-threatening Death not indicated intervention indicated invasive intervention consequences; urgent indicated; hospitalization intervention indicated Definition:A disorder characterized by bleeding from the pancreas. Navigational Note: Salivary gland fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between a salivary gland and another organ or anatomic site. Signs and symptoms may include induration, erythema, swelling, burning sensation and marked discomfort at the infusion site. Navigational Note: Injection site reaction Tenderness with or without Pain; lipodystrophy; edema; Ulceration or necrosis; severe Life-threatening Death associated symptoms. Vaccination site Local lymph node Localized ulceration; - lymphadenopathy enlargement generalized lymph node enlargement Definition:A disorder characterized by lymph node enlargement after vaccination. Navigational Note: Biliary fistula Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the bile ducts and another organ or anatomic site. Navigational Note: Budd-Chiari syndrome Medical management Severe or medically significant Life-threatening Death indicated but not immediately life- consequences; moderate to threatening; hospitalization or severe encephalopathy; coma prolongation of existing hospitalization indicated; asterixis; mild encephalopathy Definition:A disorder characterized by occlusion of the hepatic veins and typically presents with abdominal pain, ascites and hepatomegaly. Navigational Note: Cholecystitis Symptomatic; medical Severe symptoms; invasive Life-threatening Death intervention indicated intervention indicated consequences; urgent operative intervention indicated Definition:A disorder characterized by inflammation involving the gallbladder. Navigational Note: Gallbladder fistula Asymptomatic Symptomatic, invasive Invasive intervention Life-threatening Death intervention not indicated indicated consequences; urgent intervention indicated Definition:A disorder characterized by an abnormal communication between the gallbladder and another organ or anatomic site. Navigational Note: Gallbladder perforation - Life-threatening Death consequences; urgent intervention indicated Definition:A disorder characterized by a rupture in the gallbladder wall. Navigational Note: Portal vein thrombosis Intervention not indicated Medical intervention Life-threatening Death indicated consequences; urgent intervention indicated Definition:A disorder characterized by the formation of a thrombus (blood clot) in the portal vein. Navigational Note:If related to infusion, use Injury, poisoning and procedural complications: Infusion related reaction. Anaphylaxis - Symptomatic bronchospasm, Life-threatening Death with or without urticaria; consequences; urgent parenteral intervention intervention indicated indicated; allergy-related edema/angioedema; hypotension Definition:A disorder characterized by an acute inflammatory reaction resulting from the release of histamine and histamine-like substances from mast cells, causing a hypersensitivity immune response. Navigational Note: Autoimmune disorder Asymptomatic; serologic or Evidence of autoimmune Autoimmune reactions Life-threatening Death other evidence of reaction involving a non- involving major organ. Navigational Note: Bacteremia Blood culture positive with no - signs or symptoms Definition:A disorder characterized by the presence of bacteria in the blood stream. Navigational Note: Endophthalmitis Local intervention indicated Systemic intervention; Best corrected visual acuity of hospitalization indicated 20/200 or worse in the affected eye Definition:A disorder characterized by an infectious process involving the internal structures of the eye. Navigational Note: Hepatitis viral Asymptomatic, intervention Moderate symptoms; medical Symptomatic liver Life-threatening Death not indicated intervention indicated dysfunction; fibrosis by consequences; severe biopsy; compensated decompensated liver function cirrhosis; hospitalization or. Symptoms include fullness, itching, swelling and marked discomfort in the ear and ear drainage. Clinical manifestations include erythema, marked discomfort, swelling, and induration along the course of the infected vein. Navigational Note: Viremia Moderate symptoms; medical Severe or medically significant - intervention indicated but not immediately life- threatening; hospitalization or prolongation of existing hospitalization indicated Definition:A disorder characterized by the presence of a virus in the blood stream. Navigational Note: Biliary anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage of bile due to breakdown of a biliary anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Dermatitis radiation Faint erythema or dry Moderate to brisk erythema; Moist desquamation in areas Life-threatening Death desquamation patchy moist desquamation, other than skin folds and consequences; skin necrosis mostly confined to skin folds creases; bleeding induced by or ulceration of full thickness and creases; moderate edema minor trauma or abrasion dermis; spontaneous bleeding from involved site; skin graft indicated Definition:A finding of cutaneous inflammatory reaction occurring as a result of exposure to biologically effective levels of ionizing radiation. Navigational Note: Fall Minor with no resultant Symptomatic; noninvasive Hospitalization indicated; - injuries; intervention not intervention indicated invasive intervention indicated indicated Definition:A finding of sudden movement downward, usually resulting in injury. Navigational Note: Fallopian tube anastomotic Asymptomatic; clinical or Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak diagnostic observations only; intervention indicated intervention indicated consequences; urgent intervention not indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a fallopian tube anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Gastrointestinal anastomotic Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death leak finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a gastrointestinal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Infusion related reaction Mild transient reaction; Therapy or infusion Prolonged. Navigational Note: Postoperative thoracic Extubated within 24 72 hrs Extubated >72 hrs Life-threatening airway Death procedure complication postoperatively postoperatively, but before compromise; urgent tracheostomy indicated intervention indicated. Navigational Note: Prolapse of urostomy Asymptomatic; clinical or Local care or maintenance; Dysfunctional stoma; elective Life-threatening Death diagnostic observations only; minor revision indicated operative intervention or consequences; urgent intervention not indicated major stomal revision intervention indicated indicated Definition:A finding of displacement of the urostomy. The inflammatory reaction is confined to the previously irradiated skin and the symptoms disappear after the removal of the pharmaceutical agent. Navigational Note: Rectal anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a rectal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Urethral anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a urethral anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Urostomy leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage of contents from a urostomy. Navigational Note:For systemic vaccination complications, consider Immune system disorders: Allergic reaction or Anaphylaxis. Vaginal anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a vaginal anastomosis (surgical connection of two separate anatomic structures). Navigational Note: Vas deferens anastomotic leak Asymptomatic diagnostic Symptomatic; medical Severe symptoms; invasive Life-threatening Death finding; intervention not intervention indicated intervention indicated consequences; urgent indicated operative intervention indicated Definition:A finding of leakage due to breakdown of a vas deferens anastomosis (surgical connection of two separate anatomic structures). Navigational Note:Prior to using this term consider Injury, poisoning and procedural complications: Wound dehiscence or Infections and infestations: Wound infection Wound dehiscence Incisional separation, Incisional separation, local Fascial disruption or Life-threatening Death intervention not indicated care. Cardiac troponin T increased Levels above the upper limit Levels consistent with - of normal and below the level myocardial infarction as of myocardial infarction as defined by the manufacturer defined by the manufacturer Definition:A finding based on laboratory test results that indicate increased levels of cardiac troponin T in a biological specimen. Report Cardiac disorders: Heart failure or Cardiac disorders: Myocardial infarction if same grade event. Report Cardiac disorders: Left ventricular systolic dysfunction if same grade event. Navigational Note: Hemoglobin increased Increase in >0 2 g/dL Increase in >2 4 g/dL Increase in >4 g/dL - Definition:A finding based on laboratory test results that indicate increased levels of hemoglobin above normal. Navigational Note: Lymphocyte count increased >4000/mm3 20,000/mm3 >20,000/mm3 - Definition:A finding based on laboratory test results that indicate an abnormal increase in the number of lymphocytes in the blood, effusions or bone marrow. Navigational Note:If intervention initiated or symptomatic, report as Endocrine disorders: Hypothyroidism. Urine output decreased - Adult:Oliguria (<80 ml in 8 Adult:Anuria (<240 ml in 24 hr); hr); Infants:< 0. Navigational Note: Anorexia Loss of appetite without Oral intake altered without Associated with significant Life-threatening Death alteration in eating habits significant weight loss or weight loss or malnutrition consequences; urgent malnutrition; oral nutritional. Navigational Note: Glucose intolerance Asymptomatic; clinical or Symptomatic; dietary Severe symptoms; insulin Life-threatening Death diagnostic observations only; modification or oral agent indicated consequences; urgent intervention not indicated indicated intervention indicated Definition:A disorder characterized by an inability to properly metabolize glucose. Navigational Note: Iron overload Moderate symptoms; Severe symptoms; Life-threatening Death intervention not indicated intervention indicated consequences; urgent intervention indicated Definition:A disorder characterized by accumulation of iron in the tissues. Navigational Note:Use term Investigations: Weight gain Tumor lysis syndrome - Present Life-threatening Death consequences; urgent intervention indicated Definition:A disorder characterized by metabolic abnormalities that result from a spontaneous or therapy-related cytolysis of tumor cells. Navigational Note: Musculoskeletal deformity Cosmetically and functionally Deformity, hypoplasia, or Significant deformity, - insignificant hypoplasia asymmetry able to be hypoplasia, or asymmetry, remediated by prosthesis unable to be remediated by. Navigational Note: Soft tissue necrosis lower limb Local wound care; medical Operative debridement or Life-threatening Death intervention indicated. Navigational Note: Myelodysplastic syndrome - Life-threatening Death consequences; urgent intervention indicated Definition:A disorder characterized by insufficiently healthy hematapoietic cell production by the bone marrow. Navigational Note: Anosmia Present - - Definition:A disorder characterized by a change in the sense of smell. Navigational Note: Cerebrospinal fluid leakage Post-craniotomy: Post-craniotomy: moderate Severe symptoms; medical Life-threatening Death asymptomatic; Post-lumbar symptoms; medical intervention indicated consequences; urgent puncture: transient headache; intervention indicated; Post- intervention indicated postural care indicated lumbar puncture: persistent moderate symptoms; blood patch indicated Definition:A disorder characterized by loss of cerebrospinal fluid into the surrounding tissues. Navigational Note: Cognitive disturbance Mild cognitive disability; not Moderate cognitive disability; Severe cognitive disability; - interfering with interfering with significant impairment of work/school/life work/school/life performance work/school/life performance performance; specialized but capable of independent educational services/devices living; specialized resources not indicated on part time basis indicated Definition:A disorder characterized by a conspicuous change in cognitive function. Navigational Note: Dysarthria Mild slurred speech Moderate impairment of Severe impairment of - articulation or slurred speech articulation or slurred speech Definition:A disorder characterized by slow and slurred speech resulting from an inability to coordinate the muscles used in speech. Navigational Note: Dysgeusia Altered taste but no change in Altered taste with change in - diet diet. Navigational Note: Ischemia cerebrovascular Asymptomatic; clinical or Moderate symptoms - diagnostic observations only; intervention not indicated Definition:A disorder characterized by a decrease or absence of blood supply to the brain caused by obstruction (thrombosis or embolism) of an artery resulting in neurological damage. Navigational Note: Recurrent laryngeal nerve Asymptomatic; clinical or Moderate symptoms Severe symptoms; medical Life-threatening Death palsy diagnostic observations only; intervention indicated. It has been observed in association with hypertensive encephalopathy, eclampsia, and immunosuppressive and cytotoxic drug treatment. Navigational Note: Syncope - Fainting; orthostatic collapse - Definition:A disorder characterized by spontaneous loss of consciousness caused by insufficient blood supply to the brain. Navigational Note: Tendon reflex decreased Ankle reflex reduced Ankle reflex absent; other Absence of all reflexes - reflexes reduced Definition:A disorder characterized by less than normal deep tendon reflexes. Navigational Note: Pregnancy loss - Fetal loss at any gestational age Definition:Death in utero. Navigational Note: Anorgasmia Inability to achieve orgasm Inability to achieve orgasm - not adversely affecting adversely affecting relationship relationship Definition:A disorder characterized by an inability to achieve orgasm. Navigational Note: Delayed orgasm Delay in achieving orgasm not Delay in achieving orgasm - adversely affecting adversely affecting relationship relationship Definition:A disorder characterized by sexual dysfunction characterized by a delay in climax. Navigational Note: Psychosis Mild psychotic symptoms Moderate psychotic Severe psychotic symptoms Life-threatening Death symptoms. Navigational Note: Bladder spasm Intervention not indicated Antispasmodics indicated Hospitalization indicated - Definition:A disorder characterized by a sudden and involuntary contraction of the bladder wall. Navigational Note: Dysuria Present - - Definition:A disorder characterized by painful urination. Navigational Note: Urine discoloration Present - - Definition:A disorder characterized by a change in the color of the urine. Navigational Note: Breast atrophy Minimal asymmetry; minimal Moderate asymmetry; Asymmetry >1/3 of breast - atrophy moderate atrophy volume; severe atrophy Definition:A disorder characterized by underdevelopment of the breast.

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