Mark Corson

By C. Rathgar. Alfred State College, State University of New York College of Technology.

Occasionally cheap 10 mg deltasone overnight delivery, kidney stones that migrate to the distal ureter cause pain referred to the groin order deltasone 10mg visa, but this pain usually is colicky in nature buy deltasone 20 mg amex. Testis Torsion The patient who presents with acute testis pain should be treated as a surgical emergency. A patient who has a testis torsion and is not treated within 3 to 12 hours may suffer testis atrophy. Testis torsion occurs because the testis rotates or twists its blood supply, essentially strangling the testis. Testis torsion usually occurs in adolescent males, but it may be seen in cryptorchid testis or as a result of testis trauma. The patient’s history of torsion usually is consistent with sudden onset, acute pain, nausea, and vomiting. The patient should have a urinalysis, urine culture and sensitivity, and complete blood count Acute testis pain Duration Differential History and Physical – Torsion of testis – Epididymo-orchitis – Trauma – Hernia – Appendix – Torsion of Appendages Scrotal Trauma: ultrasound – Conservative – Surgery if testis is ruptured or Conservative therapy tunica albuginea is violated Hernia Surgery if incarcerated Epididymo-orchitis Torsion of testis Antibiotic – Surgical treatment treatment Torsion of appendage – Surgical or conservative management Algorithm 39. Physical examination of the patient with torsion reveals a tender, ery- thematous scrotum with a high or horizontal position of the testis. Epididymitis usually presents with gradual onset, white blood cells in the urine, and increased ten- derness behind the testis along the epididymis. The patient may have a history of recent sexual activity or symptoms of urinary infection or prostatitis. A testis torsion appears as hypovascular, while epi- didymitis appears as hypervascular. Since Doppler ultrasonography technology has improved, nuclear scanning rarely is necessary to confirm the diagnosis. For treatment, manual detorsion may be attempted if the torsion has occurred within a few hours. This consists of infiltration of the sper- matic cord near the external ring with lidocaine. The left testis is rotated counterclockwise manually, while the right testis is rotated clockwise manually. Manual detorsion usually is not effective because of the patient’s degree of pain. Emergent surgical scrotal exploration should be performed under general anesthesia. A scrotal incision is made, the spermatic cord is untwisted, and the testis is inspected. If the testis appears viable, it should be sutured in place to the surrounding tissue. The contralateral testis also should undergo orchiopexy during the same procedure. Torsion of the testicular appendages may mimic testis torsion and usually occurs in boys younger than 16 years of age. The appendix testis (remnant of the Müllerian duct) and appendix epididymis (remnant of the Wolffian duct) may twist and cause venous engorge- ment and infarction, producing the “blue-dot sign. If the pain persists or there is concern of testis torsion, emergent surgical exploration should be performed. Case Discussion The patient in Case 2 stated that the pain occurred suddenly about 2 hours previously and continued to be unbearable. Urinalysis was negative for white blood cells, and Doppler ultrasonography revealed decreased flow to the testis. The patient underwent emergent scrotal exploration in the operating room, where a testis torsion was found. The testis was sutured to sur- rounding tissue (orchipexy) to prevent future torsion and the con- tralateral testis also underwent orchiepexy. Epididymo-orchitis Acute epididymitis is extremely painful and may mimic the symptoms of testicular torsion. It is caused by urinary tract pathogens, such as gram-negative organisms, and often originates from prostatitis or an indwelling urethral catheter. Acute epididymitis also can be associated with sexually transmitted diseases, such as those caused by Chlamydia trachomatis or Neisseria gonorrhea. Laboratory findings reveal white blood cells in the urine and a pos- itive Gram stain. Ultrasonography reveals a hypervascular area consis- tent with the inflammatory response of infection. If a urinary pathogen is suspected, the patient should be given a quinolone or a trimethoprim sulfate until urine and blood culture sensitivities return. If a sexually transmitted disease is suspected, the patient should be given an injection of ceftriaxone followed by oral doxycycline or tetra- cycline. Depending on the severity of the infection, the patient may need pain medications, ice packs to the scrotum, and bed rest. Some patients progress to chronic epididymitis and require long-term antibiotic coverage and nonsteroidal antiinflammatory medication. Testis Masses Testis masses include benign lesions of the scrotum and testis tumors. They usually are benign, but they must be differentiated from testis tumors and inguinal hernias.

Whilst Amy constructed experimentation as imposed by the psychiatrist discount deltasone 20 mg fast delivery, however generic deltasone 40 mg with mastercard, others indicated that they trialled various medications in collaboration with prescribers generic 40 mg deltasone free shipping, as part of the process of finding a suitable medication and dosage. In the following extract, George talks about how his distrust of “doctors” due to his perception of them as having power over not only his treatment but his finances: George, 14/8/08 G: Coz like, I um, sorta lied, I said I wasn’t taking more marijuana, you know, thought I’d just gave it up because I was feeling sick and every time 219 she’d ask, I’d just tell her, no, no I don’t take it. Coz if you tell ‘em that you’re taking it they’ll just take your money off you, you know? George states that he is dishonest with his prescriber (“I um, sorta lied”) and strategically hides information relevant to his treatment due to fear of the consequences of not following his doctor’s orders, namely: “they’ll just take your money off you”. George could be seen to position prescribers as punitive when consumers use drugs in addition to their prescriptions. He constructs his perception of prescribers as based on his past experiences of having to submit his money to the control of a public trustee and indicated that this occurs regularly to consumers by pointing out that it has been documented in the media (“they’ve been on television and all”). It could be argued that George’s lack of openness with his prescriber compromises the prescriber’s ability to assist George to address his drug use, which may represent a barrier to his adherence or, in the least, could contraindicate the therapeutic benefits of taking medication. Indeed, if discussions related to drug use are considered taboo, then so may be discussion related to non- adherence and other potential adherence barriers. Unlike in previous extracts, however, he indicates that the threats his prescriber makes to punish him for non-adherence motivate him to remain adherent. Similarly, Gavin, in the latter extract, suggests that adherence could be enhanced if service providers warn consumers of the increased risk of hospitalization associated with non-adherence: Matthew, 18/2/09 M: Nah, that’s my psychiatrist, yep. You don’t take your clozapine, you’re not very um, good and you’re sick so straight to the lock up ward, he said, you know, if I don’t take my clozapine. Gavin, 11/2/09 L: How do you think consumers could be encouraged to take their medication? G: Say to them, if you wanna stay out of hospital, you better take your medication. Everyone seems to say this, it’s sort of like saying you’re going to jail or something. According to Matthew, his doctor appraises him negatively, as “not very um, good” and “sick” when he is non-adherent. He elaborates that if he is non-adherent, his psychiatrist threatens to send him “straight to the lock up ward” in hospital. Matthew reported that his psychiatrist’s threats “freaked” him out and, thus, motivate his adherence (“So I take it”). Thus, whilst some consumers reported rebelling against punitive and controlling psychiatrists by becoming non-adherent, as will be illustrated in subsequent extracts, Matthew’s account represents a different perspective, that fear as a result of service providers’ threats of punishment for non-adherence can enhance some consumers’ adherence. In the latter extract, when asked how to encourage adherence amongst consumers, Gavin proposes that service providers highlight the association between non-adherence and the risk of hospitalization to deter non-adherence (“Say to them, if you wanna stay out of hospital, you better take your medication”). Of note, the directive, “you better take your medication” could be seen as potentially threatening. Gavin 222 concurs with the interviewer that hospital shares similarities with jail for consumers, adding that “you can’t go nowhere, you’ve gotta stay there” and also states that inpatients can represent sources of fear due to their unpredictability (“You don’t know if they’re cracking up at you”). Matthew can be seen to suggest that the power imbalance operating within the therapeutic alliance between him and his psychiatrist, which manifests as threats of punishment for non-adherence, supports his adherence and, similarly, Gavin encourages service providers to warn consumers of the negative consequences of non-adherence to support adherence. Interestingly, Gavin describes hospital as limiting consumers’ agency and, thus, as a system in which significant power imbalances operate. This construction could be seen to partly account for his support for authoritative intervention, which may represent a means of avoiding more significant power imbalances that operate in hospital settings. In the following extract, Brodie positions his prescriber as a knowledgeable expert, whom he entrusts control over his treatment: Brodie, 21/8/08 L: So you know that time when you um, asked for your dose to be lowered, how come you asked to have it lowered? B: I think coz I, I figured I could still be alright without 10mg but I guess not, but um, it was too low. It wasn’t-, I don’t think I was better at the time, um (inaudible) probably too soon, but like I said, it’s not up to me, it’s up to the mental health, up to the psychiatrist to prescribe all that stuff. Brodie recalled previously requesting to have his dosage lowered as he “figured [he] could still be alright” which was then disproven by his experience (“but I guess not”). He could be seen to relate this experience to his present trust in his prescriber to manage his treatment. Whilst Brodie may appear to position himself as subservient to his prescriber, his decision to allow his prescriber to dictate his medication regiment could also be seen to reflect a sensible, rational choice and an attempt to ensure that his treatment decisions are not influenced by his mental instability. That is, in the context of mental instability, allowing the prescriber to have control over the treatment regimen may be more beneficial for consumers, thus, challenging whether true collaboration is a positive goal, when consumers’ symptoms are florid and their judgment is potentially impeded. This is contrasted with interviewees’ experiences of prescribers focusing solely on illness symptoms or prescription information, asking the same questions week after week and, generally, adopting a more impersonal approach to treatment. In line with research which indicates that longer duration of treatment with the same prescriber influences adherence (i. Below, interviewees highlight the types of questions they think prescribers should ask them and contrast this to a lack of interest in consumer experiences: Gary and Ruth, 31/07/2008 L: Cool, thanks. Ummm, so are there any other ways that you think um health workers could help people, could assist people in ta-, to take their medications? G: Well, umm, see I think that health workers don’t ask enough questions, you know what I mean? G: They just ask you how you, you know, they ask you how are your symptoms and you tell ‘em your symptoms and…you know like the psychiatrists I’ve had, they seem to be a bit ignorant, you know what I mean? L: Oh ok, so they’ll just ask about how your symptoms are and not so much about your experiences with, of taking the medication.

As with Crohn’s disease proximally purchase deltasone 20mg without a prescription, palliation of symptoms and preservation of functional bowel are the priorities guiding surgical intervention generic 40mg deltasone visa. Likewise purchase 20mg deltasone mastercard, the aim of therapy is the treatment of complications of disease rather than the disease itself. Two mandates clarify these prin- ciples with respect to perianal disease: (1) the management of a septic focus is an indication for surgery, and (2) the sphincter should be pre- served as long as the patient is coping well. Colon and Rectum 453 ineal lesions often appear, they surprisingly are well tolerated. In fact, the complaint of pain is indicative of an abscess, and surgical consul- tation should be arranged promptly. Although the medical therapy is similar for Crohn’s disease and ulcerative colitis, the surgical therapies for each differ greatly, and it is imperative that a clear diagnosis is made whenever possible. The clinical manifestations of ulcerative colitis vary with the sever- ity of the disease. Patients with mild disease may have occasional blood and mucus and a moderate number of stools. Frequent, explo- sive diarrhea with significant bleeding or discharge of mucus and pus manifests more severe disease. Severe disease also may be associated with fever, abdom- inal pain, tenesmus, malaise, anemia, or weight loss. Most patients present with mild to moderate disease involving the rectum and a contiguous segment of the distal colon. The so-called toxic “megacolon” is a presentation of fulminant colitis with fever, abdominal pain, and leukocytosis that may or may not be associated with radiographic evi- dence of colonic dilatation. As presented in Case 1, patients may require emergent operation for perforation or resistance to medical therapy. A sig- moidoscopy may be diagnostic, and colonoscopy is hazardous (per- foration) when active disease is present. Surveillance by colonoscopy in ulcerative colitis is important because of the increased risk of colo- rectal dysplasia and carcinoma. Patients at higher risk are those with colitis proximal to the splenic flexure and those with long-standing disease, at least 8 to 10 years. The extraintestinal manifestations of ulcerative colitis are similar to those of Crohn’s disease, with the exception of hepatobiliary compli- cations, which are more common and can be quite severe. Medical Therapy: The medical therapy for ulcerative colitis overlaps significantly with those therapies used for Crohn’s disease, discussed earlier. Eisenstat Consider for Hemorrhage sphincter Abdominal Indications for Perforation preservation colectomy with urgent surgery at a later date Toxic colitis ileostomy when health Megacolon has been restored Total proctocolectomy and Brook ileostomy Refractory to medical Rx Poor sphincter Steroid dependent function Subtotal colectomy with Stricture Brook ileostomy Indications for (later proctectomy) elective surgery Dysplasia Intolerable side effects Adbominal colectomy of medication with ileorectal Adequate sphincter anastomosis Failure to thrive function High cancer risk Colectomy, proctectomy, ileopouch—anal anastomosis, temporary ileostomy Algorithm 25. Surgical Therapy: Approximately 30% of all patients with ulcerative colitis ultimately have surgery. For patients with chronic active or quiescent disease, the indications for surgery include an inability to wean from steroids, extracolonic manifestations that may respond to colectomy, and the presence of dysplasia or carcinoma on colonoscopy screening. The ileal pouch–anal anastomosis has become the standard opera- tion for ulcerative colitis. The advantage of the procedure is that it allows the patient to void per anus, thus avoiding a stoma. The disad- vantages are that the procedure is associated with significant morbid- ity and that the risk of cancer is not completely eliminated, as it is when a standard proctocolectomy is performed. As the incidence of divertic- ulosis increases with age, the risk of complications, other than bleed- ing, does not increase. In fact, the risk of complications related to perforation may be higher in the younger age groups. Medical treat- ment is less effective for recurrent attacks, and complications associ- ated with an acute attack increase from 23% for the first attack to 58% after more than one attack. Colon and Rectum 455 in approximately 1% of patients with the disease, whereas nearly one third of symptomatic patients may require surgery at some point. Colonoscopy is preferred over barium enema in the initial workup of suspected diverticular disease because of its superior sensitivity and specificity. However, colonoscopy is less rewarding and more danger- ous in the evaluation of acute complications of perforated diverticular disease. Fiber is the mainstay of the medical management of uncomplicated diverticulosis or mild diverticulitis. A high-fiber diet is believed to reduce intracolonic pressures, presumably eliminating the “cause” of diverticular disease. Complications of colonic diverticula that may require surgical con- sultation or intervention are hemorrhage and the complications of perforation of a diverticulum, which include chronic left lower quad- rant pain, phlegm, abscess, peritonitis, fistula, and stricture. The source of the bleeding is generally right sided, even though the diverticula predominantly are present on the left. The majority of patients (70–82%) stop bleeding; up to one third continue to bleed and require intervention. Once resuscitation is under way, attention is directed toward local- ization of the source. If the nasogastric tube and proctosigmoidoscopic evaluation suggest a distal source, a nuclear medicine test is the pre- ferred first step. Angiographic localization is attempted in those with a positive nuclear medicine scan. In most cases, the perforation is microscopic, causing localized inflam- mation in the colonic wall or paracolic tissues.

Although Because of their location and constant use buy discount deltasone 10 mg line, joints the joint chiefly affected is the big toe order 40mg deltasone with visa, any joint are prone to stress injuries and inflammation cheap 5 mg deltasone free shipping. Sometimes, renal calculi main types of arthritis include rheumatoid arthri- (nephroliths) form because of uric acid crystals tis, osteoarthritis, and gouty arthritis, or gout. Proximal interphalangeal joints Metacarpophalangeal joints Wrist bones Figure 10-12. Pathology 287 Muscular Dystrophy that arise in another region of the body and spread Muscular dystrophy, a genetic disease, is charac- (metastasize) to bone, called secondary bone can- terized by gradual atrophy and weakening of mus- cer. The most common type, Duchenne dys- caused by malignant cells that have metastasized trophy, affects children; boys more commonly than to the bone from the lungs, breast, or prostate. It is transmitted as a sex-linked disease passed Malignancies that originate from bone, fat, mus- from mother to son. As muscular dystrophy pro- cle, cartilage, bone marrow, and cells of the lym- gresses, the loss of muscle function affects not only phatic system are called sarcomas. At present, types of sarcomas include fibrosarcoma, osteosarco- there is no cure for this disease, and most children ma, and Ewing sarcoma. It usually affects the shaft of long stance that transmits nerve impulses (neurotransmit- bones but may occur in the pelvis or other bones of ter). This disease usually affects young increasingly weak and may eventually cease to function boys between ages 10 and 20. Women tend to be affected more often Signs and symptoms of sarcoma include swelling than men. Initial symptoms include a weakness of the and tenderness, with a tendency toward fractures in eye muscles and difficulty swallowing (dysphagia). Eventually, the muscles of the limbs may become scan are diagnostic tests that assist in identifying involved. Ewing sarcoma, are staged and graded to determine the extent and degree of malignancy. This staging helps the physician determine an appropriate treat- Oncology ment modality. Generally, combination therapy is The two major types of malignancies that affect used, including chemotherapy for management of bone are those that arise directly from bone or metastasis and radiation when the tumor is radi- bone tissue, called primary bone cancer, and those osensitive. Diagnostic, Symptomatic, and Related Terms This section introduces diagnostic, symptomatic, and related terms and their meanings. Treatment consists of applying casts to progressively straighten the foot and surgical correction for severe cases. It is time to review pathological, diagnostic, symptomatic, and related terms by completing Learning Activity 10–5. Descriptions are provided as well as pronunciations and word analyses for selected terms. It is used to identify or differentiate traumatic fractures, spondylosis, sacr: sacrum spondylolisthesis, and metastatic tumor. Pathology 291 Diagnostic and Therapeutic Procedures—cont’d Procedure Description bone Scintigraphy procedure in which radionuclide is injected intravenously and taken up into the bone Bone scintigraphy is used to detect bone disorders, especially arthritis, fractures, osteomyelitis, bone cancers, or areas of bony metastases. Areas of increased uptake (hot spots) are abnormal and may be infection or cancer. Therapeutic Procedures reduction Procedure that restores a bone to its normal position Following reduction, the bone is immobilized with an external device to main- tain proper alignment during the healing process. Often internal f ixation devices such as nails, screws, or plates are required to f ix the fracture fragments in their correct anatomical position. The most common reason for limb loss is peripheral vascular disease caused by a blood flow blockage from cigarette smoking, physical inactivity, or uncontrolled diabetes mellitus. Arthroscopy is also performed to correct defects, excise tumors, and obtain biopsies. Femur Patella Knee Irrigating instrument Trimming Viewing instrument scope Fibula Tibia Figure 10-14. The acetabulum is plastic coated to avoid metal-to-metal contact on articulating surfaces; the stem is anchored into the central core of the femur to achieve a secure f it. Pelvis Acetabulum cap Femoral neck and head Acetabulum Femoral shaft Femur Femur A. Calcium supplements are used to treat are treated with analgesics and anti-inflammatory hypocalcemia. Table 10-3 Drugs Used to Treat Musculoskeletal Disorders This table lists common drug classifications used to treat musculoskeletal disorders, their therapeutic actions, and selected generic and trade names. Classification Therapeutic Action Generic and Trade Names calcium supplements Treat and prevent hypocalcemia. Cal-Citrate 250, Citracal Pharmacology 295 Table 10-3 Drugs Used to Treat Musculoskeletal Disorders—cont’d Classification Therapeutic Action Generic and Trade Names gold salts Treat rheumatoid arthritis by inhibiting activity auranofin within the immune system. This agent prevents further disease aurothioglucose progression but cannot reverse past damage. Complete each activity and review your answers to evaluate your understand- ing of the chapter. Learning Activity 10-1 Identifying Muscle Structures Label the following illustration using the terms listed below. Triceps brachii Brachialis Triceps brachii Achilles tendon gastrocnemius rectus abdominus biceps brachii gluteus maximus soleus biceps femoris masseter sternocleidomastoid brachioradialis orbicularis oculi trapezius deltoid pectoralis major Check your answers by referring to Figure 10–1 on page 267. Learning Activity 10-3 Identifying Skeletal Structures Label the following illustration using the terms listed below.

Chapter 7: Correcting Your Life-Lenses: A New Vision 109 Worksheet 7-13 Adam’s Then and Now Exercise Problematic Life-Lens Childhood Image(s) Current Triggers Vulnerable: I’m The image of a gun When someone suddenly scared purchase 40 mg deltasone overnight delivery. The pointing at me is burned cuts me off in traffic buy deltasone 5 mg with visa, I feel world feels very deeply into my brain cheap 20mg deltasone otc. Take some time to fill out the Then and Now Exercise (see Worksheet 7-14) for each problematic life-lens that you identified in Worksheet 7-1 earlier in this chap- ter. Whenever one of your problematic life-lenses is activated, refer back to this form in order to remind yourself that your feelings and reactions today have more to do with yesteryear than with your current reality. In the left-hand column, write down one of the problematic life-lenses that you rated as 3 or above on your Problematic Life-Lens Questionnaire (see Worksheet 7-1). Also include a brief definition of the life-lens based on your reflections from Worksheet 7-2. Reflect on your childhood and, in the middle column, record any memories or images that probably had something to do with the development of your life-lens. Be on the lookout for events that trigger your life-lens, and write those events down in the right-hand column as they occur. Because each lens often has multiple images and a variety of triggers, you should fill out a sep- arate form for each problematic life-lens. And whenever your problematic life-lens is triggered, review this Then and Now Exercise as a reminder of what your reaction is actually all about. For almost any problematic life-lens, you need to employ an array of strategies in order to feel significant benefit. Don’t expect a single exercise to “cure” you, and always consider professional help if your own efforts don’t take you far enough. After you complete the exercise, take some time to reflect on what you’ve learned about yourself and your feelings, and record your reflections in Worksheet 7-15. Worksheet 7-15 My Reflections Tallying up costs and benefits of current life-lenses The process of changing life-lenses stirs up some anxiety in most people. That’s because people believe (whether consciously or unconsciously) that life-lenses either protect or benefit them in some important ways. For example, if you have a vulnerable life-lens, you probably think that seeing the world as dangerous helps you avoid harm. Or if you possess a dependency life-lens, you likely think that it guides you to find the help from others that you truly need. Only when you fully believe that your life- lenses cause you more harm than good do you have the motivation to change them. Cameron rarely sets limits on himself or others and doesn’t think he should have to. His high intelligence and easy-going personality have enabled him to get by — until recently. Hangovers often cause him to miss classes, and his grades, pre- viously hovering just above passing, sink into the failure zone. Alarmed, his parents encourage him to see someone at the Student Mental Health Center. After discovering that Cameron looks through an under-control life-lens, his therapist suggests that he fill out a Cost/Benefit Analysis of his life-lens. Because patients often downplay the benefits of their life-lenses when they’re in therapy, his therapist suggests that he first ponder the advantages of his life-lens (see Worksheet 7-16). Chapter 7: Correcting Your Life-Lenses: A New Vision 111 Worksheet 7-16 Cameron’s Cost/Benefit Analysis (Part I) Life-Lens: Under-control. Cameron doesn’t have much trouble figuring out benefits for his problematic life-lens. However, his therapist urges him to carefully consider any negative consequences, or costs, of his under-control life-lens. I don’t have to be a slave to rules When I didn’t follow the rules about drinking and to what people tell me to do. My friends know that I say what I know I’ve hurt some good friends by what I think and that I’m honest. I like showing how I feel no It’s not always smart to express everything I matter what. I used to think they were just boring, but I see that, in some ways, they seem happier than I am. As Cameron wraps up his Cost/Benefit Analysis, he comes to a realization: “My under-control life-lens is ruining my life! A Cost/Benefit Analysis helps you boost your motivation to regrind problematic life-lenses. Write down one of the problematic life-lenses that you identified in Worksheet 7-1. Also, include a brief definition of the life-lens based on your reflections in Worksheet 7-2. Think about any and all of the conceivable benefits for your problematic life-lens and record them in the left-hand column. In the right-hand column, record any and all conceivable costs of your problematic life-lens. It’s a good idea to start by looking at the presumed benefits and responding with a counterargument. Make a decision about whether the dis- advantages or costs outweigh the advantages or benefits. Worksheet 7-18 My Cost/Benefit Analysis Life-Lens: Benefits Costs Chapter 7: Correcting Your Life-Lenses: A New Vision 113 Benefits Costs Go to www. Worksheet 7-19 My Reflections Taking direct action against problematic life-lenses The exercises in the previous two sections were designed to increase your motivation and set the stage for altering your life-lenses. In this section, our guidelines for developing an action plan show you how to prepare for an all-out assault on your life-lenses.