clinic presents

anonymous asked:

Can you explain the different type of paralysis. I have a character who is magical and has the paralysis where it's an on and off thing with their legs. I was wondering if it was possible for them to be able to drive or operate Machinery like a motorcycle or a car. What would be the limits to what they can do because I want them to pose as human as possible.

Hey there nonny. A lot of what I’m going to say is going to go out the window, because you specifically mentioned magic and you specifically mention temporary paralysis (”on again / off again”). 

And this may be uncomfortable advice to get, but I’m going to ask you to read this answer all the way through, read it again, think about it, and read it a third time. 

First, talking about your character “posing as human as possible” gives me some really uncomfortable feelings about the way you may be planning to represent disability. This may be a function of the character limits in the ask box, or English may not be your first language, but the words you used implied that your character is disabled and thus not human. BAD. (Your character may be an elf or piskie or merwolf, I don’t know, but if your character is human, take a good hard look at how you’re looking at them.) 

Next: Yes, paralyzed people can drive, as long as they have some function in their arms. In fact, I worked for a quadriplegic man as his home health aide (search for Tom if you want the whole story). He could brush his teeth and comb his hair if you velcroed the implement to his hand, but he operated a car safely and effectively. Hand levers operated the brake and gas, and a control knob for the steering wheel, worked for him just fine. 

I don’t know about motorcycles, but I would assume that if he’s wheelchair-dependent, getting into and out of a motorcycle would be problematic. 

Now, on to the “on again off again” paralysis. This does exist, but not following trauma. Periodic paralysis is caused by a group of genetic disorders which change the way the body’s muscles process ions. (Muscle movement are triggered by nerves, which rely on ion changes to send electrical signals; changes in the ion channels changes or prevents electrical signals from processing). Most of them are triggered by something: heat, cold, high-carb meals. Some will have problems with high potassium (with glucose being the treatment), others will have problems with high sugar (with potassium being the treatment). 

This group of diseases is always genetic and always inherited. 

I’ll be honest: this isn’t my area of expertise. For a better understanding of the way these diseases work, I suggest you do some homework on the clinical presentation of periodic paralyses. (There’s a very good resource here; may require a free account.) 

Take care, good luck, and make sure that you take the lives of paralyzed people into account. 

xoxo, Aunt Scripty

(Samantha Keel)

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anonymous asked:

Psychiatry is not abusive and self diagnosing is dangerous. You're not a doctor and you don't know the details about all the disabilities and illnesses that are out there. Researching things on your own is fine and all, but not everything on the internet is true. Many people are often delusional and claim they have a certain disability or illness when in reality they do not, and they're merely attention seekers.

Oh gosh… here we go. First, I should probably point out that you shouldn’t assume things about other people on the Internet. You’re right, I’m not a doctor: I’m a psychologist and I most certainly have a solid understanding of the myriad diagnosable mental disorders recognized by the American Psychiatric Association. Oops.

I also have over ten years experience as a peer advocate for people who have mental health problems and/or are suffering violence at the hands of the psychiatric institution.

With that out of the way, my dear Dunning Kruger acolyte, let’s talk about all the interesting ways in which you’re painfully wrong:

First, you don’t understand what a psychiatric diagnosis even is. Diagnostic criteria for psychiatric conditions are not diseases because they do not describe an underlying disease process. They are syndromes. What that means is that your precious psychiatric diagnoses are nothing more than descriptions of various symptoms that the psychiatric profession has concluded are often seen in combination. Moreover these diagnostic criteria are:

  • Not culturally neutral. Psychiatric diagnostic criteria were developed through the observation of patients in European (incl. North American) cultures. There is extensive research by cultural anthropologists researching mental disability in non-European cultures that shows not only that psychiatric diagnoses did not seem to fit the studied population but that the importation of European psychiatry fundamentally changed the clinical presentation of the local patients.
  • Not without controversy, even within the psychiatric profession. I can think of several psychiatric diagnoses enumerated in the DSM-V that psychiatrists can’t stop bickering about regarding their validity, and that’s not including the infighting having to do with the fundamental nature of various disorders.
  • Constantly changing. Every few years a new edition of the Diagnostic and Statistical Manual of Mental Disorders comes out and diagnoses are added, dropped, and often radically changed. Two of the diagnoses that I carry, bipolar I disorder and autism spectrum disorder, changed radically in the transition from the DSM-IV-TR to the DSM-V. The latter wasn’t even a ‘real diagnosis’ until a few months ago.
  • Imprecise and subjective. Mental health professionals treating the same patient will regularly give different diagnoses from each other. Incidentally, in science we call this failing a test/retest check for reliability which is an indication that something is horseshit.
  • Helpfully bound and presented in a single volume, in plain English, for anyone with a library card or a bit of spare change to browse. Seriously. The fact that you don’t think that people who self diagnose mental disorders don’t even bother to consult a copy of the DSM-V is downright insulting. Do you really think that people who are struggling with getting help for a serious, potentially life-threatening condition restrict their research to Yahoo Answers? Grow up and give me a break. 

How is a psychiatric diagnosis made? It starts with a patient who is complaining about a symptom, or a group of symptoms that are causing them distress. You then ask them what they think is wrong with them and they give you symptoms. Having a fairly good idea of what’s wrong with your patient you now ask follow-up questions in order to differentially diagnose similar conditions. If you are very, very lucky you might even be able to directly observe a symptom or two. Then, you make your diagnosis and move on to discussing treatment options.

You wanna know what’s really useful? When a patient already has a good idea what’s wrong with them and is informed enough to know what information to volunteer. Now all you need to do is confirm the diagnosis. Having an informed patient is critical to providing quality health care of any kind.

But let’s talk about what happens when self diagnosis gets vilified by mental health professionals, as you so dearly seem to want. An anecdote from my personal life:

Before I was formally diagnosed with bipolar disorder I had serious problems with depression. My general practitioner referred me to a psychiatrist and I told her that I thought I was bipolar based on some hypomanic episodes that I felt that I had in the past. The psychiatrist brushed me off and did not ask the questions necessary to investigate my concern. She prescribed a high dose of antidepressants and sent me on my way.

If you don’t know, antidepressants cause Very Bad Things™ to happen to people who are bipolar. This is the reason why ‘bipolar II’ is a distinct diagnosis from major depression. I knew this but I also knew that if it did cause a mania it would confirm my diagnosis, so I took the drugs.

Not only did the resulting mania land me in the hospital but the drugs did permanent and severe damage. I no longer have a manageable bipolar II condition, I have a poorly controlled bipolar I condition.

So why do people self-diagnose? Because something is causing them to suffer and they either do not have access to the medical resources necessary for a formal diagnosis or they have tried to get a diagnosis but for some reason have been unable to get one.

Self-diagnosis is empowering. Self-diagnosis allows people to access the care they need from mental health professionals because they will be able to present their complaint in a way that is understandable to their healthcare provider. Self-diagnosis also allows people to research ways to cope with their symptoms without involving medical professionals.

Can a self-diagnosis be wrong? Yes. Are mental health professionals alert to errors in self-diagnosis? Yes. But here’s the thing: A mental health self-diagnosis is almost never far from the eventual, formal diagnosis.

All this being said: You’re just angry that certain people, who aren’t you, are able to advocate for themselves without going through a gauntlet of potentially abusive gatekeepers. In other words, you’re fucking scum and please get off my blog.

Before the videotapes were found, the extent of Karla Homolka’s involvement in the rapes and murders perpetrated by her husband Paul Bernardo was unknown, but once they were viewed, it showed her role was that of a willing participant.

All of the following quotes are from Invisible Darkness by Stephen Williams.

Tammy Homolka

While hesitant at first, Karla eventually agreed to let Paul rape her younger sister Tammy, a plan that came to a fatal conclusion on December 24, 1990. After plying her with alcoholic drinks laced with the Halcion she stole from her work, Tammy passed out. Karla stripped and then used a Halothane-soaked cloth to cover Tammy’s nose and mouth while Paul retrieved his video camera. Karla told Paul to put on a condom several times before giving up and saying, “Fucking do it. Just do it.” She sucked on her sister’s breasts as Paul told her to do. Then, as she was kneeling between Tammy’s legs, “Paul pushed her head down and Karla started to perform cunnilingus on her sister.” She became distraught because Tammy had her period. Paul urged Karla to finger her sister and then demanded she taste it, which she did. When Paul asked if it tasted good, “Karla looked into the camera, daubed her lips on the cuff of her white turtleneck and said, ‘fucking disgusting.’“ She later tried to claim that remark was towards the act itself. Tammy died by choking to death on her vomit.

Jane Doe

Jane Doe refers to the unidentified girl Karla knew from a former job at an animal clinic. As a wedding present, Karla invited her over to 57 Bayview Drive, spiked her drinks with Halcion, which caused her to pass out and had her waiting for Paul in their bedroom. He was worried Karla was using the same drugs that caused Tammy’s death, but she insisted everything would be fine. The following are excerpts of Karla’s role in the rape:

“Next, Karla started performing cunnilingus on Jane. She licked Jane and then raised her head, licked her lips, wagged her tongue back and forth and smiled wantonly for the camera. Then, she did the extreme close-up thing, just the way she had the previous Christmas. Only this time Karla pretended to plant a big, fat kiss on the camera lens.
Then she sucked Jane’s breasts, fir the right, then the left. When she sat up, Paul caught her smiling face.”

“Karla had kept her sleeveless lifeguard tank top on, but she was naked from the waist down. She climbed over Jane’s face, held up the tank top and rubbed her clitoris on Jane’s nose and mouth.
‘Okay, okay,’ Paul said. ‘Take her hand and put it in your cunt.’
Kneeling beside Jane, with her legs apart, Kala took Jane’s lifeless hand and rubbed it against her labia. She rotate her hips lasciviously and then got that incredible look in her eyes - that look of incomparable lust and evil that Paul loved so much.
‘Put the fingers inside you,’ he said, and Karla did just as she was told.”

Leslie Mahaffy

After Paul had kidnapped Leslie Mahaffy in the early morning hours of June 15, 1991, he woke up Karla and told her to stay in the bedroom because he had brought someone home. She then fell back asleep. When she woke up for the day and went downstairs, she suddenly became furious  Paul had used their fancy champagne glasses on Leslie. Later that day, Paul led her upstairs to the bedroom where Karla was and asked Leslie whether she’d like to have to sex with two people. She began to whimper, so Karla told Paul to “tell her the other person’s a woman.”
“Paul told her she was going to get a big kiss. He turned on the camera and watched as Karla moved in front of Leslie and bent over to give her a kiss, pushing on the younger girl’s lips twice, making it squishy and moist. Leslie did not move, but Karla knew full well that sharing this kind of kiss with another woman would excite Paul.”

“She spread the comforter and one of their electric blankets in front of the hope chest, along with her new king-size pillows. Leslie was lying with her legs spread, with Karla kneeling and kissing her vagina. Paul tried for a close-up of Karla’s face. Raising her head, she smiled and wagged her tongue with that devilish glint in her eye.”

“Karla was splayed on her back, eyes closed like a happy sunbather, while Leslie lay on her stomach with her blindfolded head between Karla’s legs.
‘Is she making you feel okay?’ Paul asked Karla, and he saw her smile.
Whatever Paul got, Karla wanted too. She moved to a kneeling position, arching her buttocks while Paul told Leslie to ‘caress and make her feel good.’
‘Put your tongue right in her asshole, push it right in.’ he said. Lesle touched Karla’s thigh, and did as she was told.
The whole scene lasted a little more than twenty-five minutes.”

In the final sequence, Karla videotaped Paul anally raping Leslie and ignored her cries in pain for help.

Kristen French

On April 16, 1992, Kristen French was kidnapped while walking home from school. This time, Karla assisted in the abduction by asking the teenager for directions as Paul forced her into the front seat of his car at knife-point. Karla made sure she didn’t move on the drive back to their house by yanking on her hair. Once inside the master bedroom, Karla directed behind the camera, telling Kristen to smile as Paul raped her and assured her she was doing a good job. The next day, Karla dressed up in the closest thing to a schoolgirl outfit she could find to match Kristen and Paul videotaped them doing “girl stuff,” such as putting on makeup and perfume. After that, “Karla knelt between Kristen’s legs and began exploring her vagina with her tongue.” Then, “While Karla lay back on the bed with both hands behind her head, Paul told Kristen to put her fingers inside, and he moved in for a close-up.
Are my nails hurting you?’ she inquired with some concern, but Karla told her it felt ‘real good.’
‘I like little girls,’ said Karla.”

“Karla brought Kristen’s hand to her breast and told her that she was a ‘good, little sex slave.’“

Karla was operating the camera once again as Kristen was performing fellatio on Paul. “Okay,’ Karla said, cuing Kristen to say a line about how she hated her boyfriend and Paul was her boyfriend and he should ‘fuck all the girls at Holy Cross,’ if it would make him happy. The bedsprings were squeaking faster and faster, when Karla interjected with the breathless information that she ‘got some good mouth shots.’
Suddenly, from the basement, there was a loud whine. The dog was feeling deprived. The sound distracted Paul but Karla urged Kristen on, calling her a ‘good cock sucker.’
‘I want to see a mouth full of cum, Kristen,’ Karla said, over the whirring motor of the camera and the baleful sound of the dog.”

In the next sequence, “the title track from Ice-T’s Power boomed over Karla, who smiled as she put the neck of an empty wine bottle all the way up Kristen’s vagina.
Using both of her hands, Karla forced the glass bottle in and out of Kristen French more than forty times.”

anonymous asked:

Heeeyy.. I know this is a little personal but I'm two months late on my period and got a negative pregnancy test.. I keep worrying but honestly I don't know what to do 😔 my boyfriend is away for boot camp and I honestly don't know who to talk to or what to do (I'm 18 and about to start college) any advice?

GO TO A DOCTOR OR HEALTH CLINIC. Sometimes pregnancy tests present false negative readings (it says so in the instructions). If you want to be 100% sure, you’ll need a blood test. If you aren’t pregnant, your late period could be a sign of another medical issue which will require a doctor. I don’t know what kind of protection you used, but sometimes late periods may also be a sign that your body doesn’t like your birth control. Again, you will need a doctor to change that. 

Don’t wait. If you are pregnant you will need to make plans quickly as to what you are going to do (whether you choose to carry to term or not, there is a time limit).

So, fun story. For every major operation/milestone, I bring my vet clinic treats. When I had my Mexican street dog spayed, I brought them chips and salsa, and a large piñata filled to the brim with candy.

Later that evening, I was sent a video of the entire staff beating the piñata and laughing maniacally.

Moral of the story: Give your vet clinic fun presents. They will appreciate it, and you will be forever loved by the staff.

@chimpannez

Ha I wish! I have Factor XII deficiency aka Hageman Factor Disorder. It is literally one in a million. It doesn’t usually present clinically but there is slight evidence of pro-thrombotic implications, which makes zero sense but shruggy guy. So I take a baby aspirin to prevent clots (which could harm me/bebe), and now I need to check with the anesthesiologist if it’s ok to inject drugs into my spinal fluid. Fun!

I’ve never thrown a clot but I guess it’s nothing to mess around with.

Past Tense, Nine-Tenths Legal

Scowl of a deceased sister
isn’t half as bad as the smile,
the warm gesture and history

at odds with this clinical
presentation, posthumous finesse
where a life only layered

sweet like bad frosting on worse
cake, for a cause, now like the ghost
knows balance, knows just how

to haunt me, guilt like possession,
and my last tenth is frail to a gale,
banshee blows down the tent.


- B B Pine

I’ve started with anatomy, so it’s more than appropriate to continue with something closely related, such as histology and embryology. Somewhere they are taught and examined together with anatomy, somewhere they are separate. I’ve been fortunate enough to have the separate course and undergo sheer histology and embryology exam. 

Keep reading

Dear Rookie,

I hope for you that you find an incredible partner. Find a mentor, a veteran on there last leg, “retired on duty”, and spark thier creativity to teach again. So much more credit should be given to experience. Find a veteran and pic thier brain. Challenge them in a respectful way. Watch them. Learn from them. Understand this field is fluid and constantly changing but some things never change. Understand that patient presentation is largely first hand experience. Those text book presentations are few and far between. You will rarely have the exact answers….and that’s ok. Base your treatment decisions on clinical presentation and a solid foundation in physiological understanding and you will be just fine. Signed, A Paramedic Friend

Lord Of The Flies psychoanalysis time:

Pretty sure Ralph was an only child and a rich spoiled boy, who had never known any hardships until the island, given how he acted at the beginning of the book and how the events on the island changed him the most out of all the boys and basically transformed him into a mature, humble boy. He was used to being praised all the time (he always expected the other boys to like him), because he was praised in his family and by other people all the time. He also had ADHD, since he presented symptoms of forgetfulness and severe lack of attention. 

Pretty sure Jack and Roger also were rich boys, but had harsher environments and strict families, given how rigid they were at the beginning and how they went wild, once they discovered the freedom. Pretty sure Jack was overshadowed in his family by an older sibling (older siblings), since he constantly tried to prove himself to everyone. And Roger was mostly ignored by his parents, since he always tried to stay quiet and in the shadows. Both of these boys clearly had Sociopathy (no matter how much people try to take Jack’s defense, he does clinically present all signs of Sociopathy, even more so than Roger himself). Sociopathy is also caused by family problems, which confirms the theory that these boys had severe families.

Pretty sure Simon had siblings, but he was the oldest out of them and had to look after them, given how mature and understanding he was of other people. Also, pretty sure Simon was either too spiritually evolved or simply had Schizophrenia (the pig scene was a hallucination specific to schizophrenic people). Or both.

My Uworld notes- 6
  • serum sickness is a type 3 HSR characterized by deposition of circulation complement fixing immune complexes and resulting vasculitis. Associated findings include fever, urticaria, arthralgias, glomerulonephritis, lymphadenopathy and a low serum c3 level 5-10 days after intravascular exposure to antigen. type 3 HSR typically activate complement at local site where immune complexes containing IgG and or IgM complement fixing antibodies have been deposited. This often results in hypocomplementemia including decreased C3 level

  • liver dz-a/w AFP

  • carcinoembryonic antigen (CEA) a/w colorectal cancer

  • CA125 -ovarian cancer. Both CEA and ca125 are fr monitoring purposes

  • PSA prostate specific antigen is most useful in establishing extent of prostate cancer and evaluating response to prostate cancer tx.

  • Iced water think cold – cold think cold agglutinins – cold agglutinin associated with infection with mycoplasma pneumonia

  • another cold agglutinin is EBV

  • free air in peritoneal cavity= bowel perforation

  • pancreatic calcification= chronic pancreatitis

  • heavily calcified vessels = atherosclerosis and vascular dz

  • distended bladder= urinary retention

  • air in billiary tract a/w gallstone ileus

  • fluoxetine a/w anorgasmia and decreased libido and increase latency to orgasm. They can however be used to tx premature ejaculation

  • phenelzine= MAO-I used in tx of depression monoamine oxidase is a mitochondrial enzyme that deaminates primary and secondary aromatic amines

  • tricyclic antidepressants can cause orthostatic hypotension example imipramine

  • trazadone- priapism

  • paroxysmal breathlessness and wheezing in young patient unrelated to ingestion of aspirin, pulmonary infection inhaled irritant stress and or exercise should raise a strong suspicion for extrinsic allergic asthma. The granule containing cells in sputum are most likely eosinophils and the crystalloid bodies are most likely Charcot Leyden crystals (contain eosinophil membrane protein)

  • chronic eosinophilic bronchitis in asthmatics involves bronchial wall infiltration by numerous activated eosinophils largely in response to IL5 released by TH2 cells

  • digestion and absorption of nutrients primarily occurs in small intestine. SI cells produce enzymes responsible for nutrient absorption. Proteins in ingested food exist primarily as polypeptides and require hydrolysis to dipeptides tripeptides and amino acid for absorption. Hydrolysis of these polypeptides is accomplished by proteolytic enzymes such as pepsin and trypsin

  • these enzymes are secreted inactive proenzymes trypsinogen and pepsinogen from stomach and pancreas

  • trypsin activates other proteolytics enzymes including chymotrypsin carboxypeptidase and elastase. Activation of trypsinogen to trypsin is achieved by enteropeptidase (or enterokinase)an enzyme produced in duodenum

  • enteropeptidase deficiency results in defective conversion of trypsinogen to active trypsin

  • lipase secreted from exocrine pancreas is the most important enzyme of digestion of triglycerides. Chronc pancreatitis is a painful condition that causes lipase deficiency. This leads to poor fat absorption and steatorrhea

  • secretin is a peptide hormone secreted by S cells of duodenum un response to low duodenal pH. Secretins timulates secretion of bicarbonate from the pancreas and gall bladder and reduces acid secretion in the stomach by reducing production of gastrin. Neutralizing the acidic pH of food entering the duodenum from the stomachis necessary for proper function of pancreatic enzymes (amylase, lipase)

  • trisomy 18 (47XX: Edwards syndrome

    • face: micrognathia, microstomia, eye defects (microphthalmis, cataracts) low set ears and malformed ears prominent occiput

    • CNS: microcephaly, neural tube defects (meningocele, anencephaly), holoprosencephaly, arnold chiri malformation, severe MR delayed psychomotor development

    • musculoskeletal: clenched hands with overlapping fingers (index finger overrides the middle fingerand fifth finger overrides the fourth finger) rocker bottom feet short sternum and hypertonia

    • cardiac: VSD, PDA

    • distinguishing features: clenched hands and or overlapping finger

    • GI: Meckel diverticulum, malrotation

    • ultrasound: intrauterine growth restriction and polyhydramnios especially ina fetus with abnormal hand arrangement

  • unlike patients with Edward’s syndrome neonates with Patau syndrome (trisomy 13) have cleft lip and palate, polydactyly and omphalocele. Patau syndrome is not a/w low set ears and overlapping fingers but do present with rocker bottom feet also

  • 47XXX karyotype is clinically silent however, some affected women have slightly decreased IQ scores. Female newborns with this karyotype are phenotypically normal with no obvious dysmorphism

  • 47XXY Kleinfelter’s syndrome: may be a/w mild mental retardation or normal intelligence. The typical patient is tall mall adult with gynecomastia small testes and infertility. Male newborns with this karyotype are phenotypically normal with no obvious dysmorphism. The clinical findings do not become apparent until adulthood.

  • Sudden onset of abdominal or flank pain hematuria and left sided varicocele together suggests renal vein thrombosis a well known complication of nephrotic syndrome. Nephrotic syndrome is a hypercoagulable state d/t increased loss of anticoagulant factors especially anti thrombinIII (responsible for the thrombotic and thromboembolic complications of nephrotic syndrome)

  • venous drainage from left testes travels throught the left testicular vein into the left renal vein and from there the IVC. In contrast to the right testicular vein which empties directly into the IVC. This difference in venous drinage gives diagnostic significance to left sided varicocele in that it often indicates an occlusion of the left renal vein by a malignant tumour or thrombus

  • malaise low grade fever followed by a facial rash. Feels better now but still has the rash- red flushed cheeks with – clinical presentation of erythema infectiosum aka fifth dz. As the facial rash fades an erythematous rash in reticular lace like pattern often appears on trunk and extremities. The rash of erythema infectiosum is thought to result at lest partly from local immune complex deposition once serum levels of virus specific IgM and IgG have attained high enough levels.

  • Erythema infectiosum= non enveloped DNA virus called parvo B19. The blood group P antigen globoside is a parvovirus B19 is highly tropic for erythrocyte precursors particularly erythrocytes and erythroid progenitor cells

  • Parvo B19 replicates predominantly in the bone marrow

  • anthracyclines daunorubicin doxorubicin epirubicin and idarubicin are chemotherapeutic agents a/w severe cardiotoxicity because of their unique ability to generate free radicals.. Dilated cardiomyopathy is dose dependent and may present months after discontinuation of the drug . Swelling of sarcoplasmic reticulum is the morphologic sign of early stage doxorubicin associated cardiomyopathy. Followed by loss of cardiomyocytes and its symptoms are those of biventricular CHF including dyspnea on exertion orthopnea and peripheral edema

  • dexrazoxane prevents Doxorubicin associated cardiomyopathy because dex is a iron chelating agent that decreases formation of free radicals by anthracyclines.

  • Restrictive cardiomyopathy a/w hemochromatosis amyloidosis sarcoidosis and radiation theraapy : remember -osis

  • hypertrophic cardiomyopathy caused by mutation of beta myosin heavy chain

  • focal cardiomyopathyscarring commonly results in MI

  • pericardial fibrosis usually follows cardiac surgery radiation therapy or viral infections of the pericardium

  • PCP aka angel dust aka phencyclidine commonly associated with violent behaviour

  • LSD can also cause aggressive behaviour but it is more typically characterized by affective liability thought disruption )delusion) and visual hallucination whereas PCP produces more psychomotor agitation including clonic jerking of extremities

  • angel dust can be put on marijuana and smoked LD is ingested orally

  • secobarbital is a street barbiturate a CNS depressant which leads to drowsy drunken state of consciousness without the violent behaviour

  • heroin (opioid) produces CNS psychomotor depression and respiratory depression miosis and bradycardia are common

  • dry tap with no splenomegaly or lymphadenopathy – think aplastic anemia which causes pancytopenia

  • aplastic anemia= hypo cellular bone marrow with fat cells and fibrotic stroma

  • hyper cellular marrow with increased blasts found in myeloproliferative d/o and certain leukemias

  • most common side effect of streptokinase= hemorrhage . Streptokinase is a thrombolytic agent that acts by converting plasminogen to plasmin which subsequently degrades fibrin. It is a foreign protein derived from streptococci and induce HSR.

  • Dissection of ascending aorta manifests as tearing chest pain that radiates to the inter-scapular area commonly occurs in hypertension marfans and ehlers danlos

  • hyperactive jaw jerk reflex when lightly tapped= chvostek’s sign- Hypocalcemic – facial m contraction elicited by tapping facial nerve just anterior to ear. The most common cause of outpatient hypocalcemia is primary hypoparathyroidism which is often d/t prior loss of parathyroid tissue during thyroidectomy

  • scotoma is visual defect that occurs d/t pathologic processes that involve parts of retina or optic nerve resulting in discrete area of altered vision surrounded by zones of normal vision. Lesions of macula cause central scotomas.. examples would include MS, diabetic retinopathy and retinitis pigmentosa

  • verapamil is a calcium channel blocker that slows SA and AV node phase 0 depolarization (in nodal cells, the phase of depolarization is mediated by calcium influx)

  • phase 0 depolarization of cardiac conduction system occurs during diastole thus verapamil slows diastolic depolarization

Basics for the Wards: Ob note

**NOTE: The field of ob-gyn is geared toward people with uteruses, and the things that can happen with ‘female anatomy’. In this post, the most common ob-gyn patient is a person with a uterus who identifies as a woman and that is the language used. I understand that not everyone with a uterus is a woman, and that not every woman has a uterus. Trans and nonbinary folks do come to ob’s for care, and I would hope all healthcare providers will respect every patient’s preferred pronouns and identity.  

This post has been mostly written by Baby Dragon (future ob-gyn extraordinaire) over my feeble attempt.

In Ob-gyn there is a lot: from routine ob-gyn notes to specifically ob/L&D notes. This post we’re going to cover how to write a note for a pregnant patient.

HPI: What brings her in today? Is it a routine prenatal visit? Is there a problem? When talking to your pregnant patients, Big four are vaginal bleeding, loss of fluid, contractions, and fetal movement. Ask every time. Even if they’re probably not feeling movement because it’s impossible (and therefore gas.) Even if it’s obviously dehydration-induced contractions. Every time. Ask about a dating ultrasound. If it’s a first visit, figuring out last menstrual period (LMP) is fine but not specific. Other things you can ask if you have time: any nausea/vomiting, how is her appetite, how is her energy, how is she sleeping, and if she is doing any physical activity.  Ex: Ms. Smith is a 25 yo who presents to clinic to confirm intrauterine pregnancy. Her last menstrual period was 8 weeks ago, home pregnancy test was positive three weeks ago. She has had nausea/vomiting every day for the last 2 weeks, crackers and ginger ale help. She would like some medication for the nausea. She has not had any spotting or abdominal/pelvic pain.

PMH/PSH: If this is a first visit, ask about medical conditions that can affect the management of her pregnancy like diabetes, hypertension, seizures, etc. Ask how many times she has been pregnant and how many living children she has had. If the number of pregnancies and the number of living children do not match, you need to find out why. This can be a sensitive subject for many women, for some they have had multiple miscarriages or a stillbirth and those lost pregnancies still hurt; some have had abortions and may feel fear of being judged for their choices.

You need extended Gs and Ps. G3P1102 = gravida, 1 term birth, 1 preterm birth, 2 living children. Previous pregnancy complications, explicitly high blood pressure, and diabetes. Were her previous deliveries vaginal or C-section, and if C-section, why. If baby went home with mom/why not. Vaccination history, especially Tdap, Hep B, flu, Rhogam in this and previous pregnancies. Rubella and varicella we get from titers so that’s fine to ignore. Ex: She is a G2P0, she has had one elective D&C at age 20. She is up to date on her vaccinations.

Meds: MAKE SURE YOU FIND OUT ALL MEDICINES, PRESCRIPTION AND OVER THE COUNTER, THAT SHE IS TAKING! So many meds are immediately off the table when a patient becomes pregnant- ibuprofen, decongestants, warfarin, many diabetes and hypertension meds, most psych meds. Be sure to emphasize the importance of taking prenatal vitamins- if she is struggling with nausea, suggest taking them at a time of day when she isn’t nauseous like right before bed. There are gummy prenatals, or if the pill is solid and too big she can break it in half (I break my prenatals in half and take them at night because the iron and fish oil made my morning nausea 100x worse) Ex: She takes Clartitin and prenatal vitamins.

Allergies: What is she allergic to and what happens? Ex: She has seasonal allergies, no known drug allergies.

FH: For family history, on top of the other things, be sure to ask about family pregnancy history. Any history of birth defects or genetic diseases in her or the father’s families? Ex: Family history is significant for maternal uncle with cystic fibrosis. Father of the baby has no significant family history that she is aware of.

SH: Who does she live with? What does she do for a living? Smoking, alcohol, and substance use history is crucial here because they are all known to negatively impact the baby. Not only are we worried about fetal health, but maternal, too. Saying something is bad for baby is fine, but “also we don’t want you to get a blood clot in your lungs that won’t let you breathe” is important.  Ex: She lives with her boyfriend of 3 years who is the father of the baby, she works as a secretary for a CEO, she does not use tobacco, alcohol, or illicit substances.

ROS: Always do a thorough head to toe review of systems.

Physical exam: Do a brief focused physical exam and you CANNOT do invasive exams by yourself. That is not even an option. You cannot do it, it’s illegal, end of sentence. If the uterus is palpable, specify where: it’s not in the pelvis anymore if you can feel it, so is it “at the umbilicus, 2cm below, 4 cm above” or not at all. Fundal height, when measured, is done for IUGR screening. Always remember why you’re doing a step when reporting the results. Formal U/S findings are separate from physical exam, like labs, since we get those from reports. Dopplers are fine in this section. Ex: Cranial nerves grossly intact, regular S1/S2 with no murmurs, lungs clear bilaterally with no wheezes, belly soft and nontender with active bowel sounds, skin clear of lesions, pelvic exam showed normal vagina and cervix with no lesions, uterus is firm and enlarged in the pelvis.

Assessment/plan: Always ask about postpartum plans. Breastfeeding, contraception, circumcision, pediatrician. Contraception especially is key, because many states and insurance plans require tubal papers signed 30 days before delivery for postpartum tubals, and LARC can require pre-auth as well. These things need to be documented extensively. It’s also a good opportunity for students to do patient education, which is rare in preggo-land. Ex: This is a healthy 25 yo G2P0000 who presents to establish pregnancy, confirmed single fetus dated by ultrasound at 8 weeks. She is having nausea/vomiting and fatigue. Told patient to take a single 25mg unisom and 75mg vitamin B6 before bedtime through the first trimester for her nausea. Followup in 4 weeks unless patient experiences bleeding or pain, will discuss contraception and breastfeeding at the next visit.

Lets Talk About Crypto

Introduction:

Cryptosporidium parvum is a zoonotic protozoan organism that causes diarrhea in calves (as well as other mammals, including humans). This protozoan invades enterocytes in the distal small intestine and large intestine. 

Transmission:

Crypto’s infective stage is the oocyst which is shed in the feces of an infected animal. Each oocyst contains four sporozoites. Healthy animals become infected with Crypto by ingesting the oocyst making Crypto predominately a fecal-oral transmission route. 

After ingesting the oocyst, the sporozoites are released and these go on to invade the cells in the intestine. The sporozoites go on to make more oocysts and the cycle continues. Invasion of intestinal cells leads to destruction of these cells which results in atrophy and fusion of intestinal villi, which causes diarrhea. 

Clinical Signs in Calves:

Calves usually present with Crypto between 1-4 weeks of age. These calves are lethargic and weak and have loose to watery stool (scours) which may be mild to severe in its intensity. Oocyst shedding begins with diarrhea and continues for several days after the resolution of clinical signs. This is important to consider when evaluating a calf after a period of isolation. 

Clinical Signs in People:

Signs of infection usually present 1 week post-exposure. Clinical signs usually consist of severe watery diarrhea, dehydration, lack of appetite, weight loss, stomach cramps, fever, nausea, and occasionally vomiting. Symptoms can last up to two weeks in length. It is for this reason that every vet student is aware of Crypto and it fondly gets the title of “the 15lb weightloss plan”. 

Diagnosis:

Diagnosis is generally made on signalment, history, and clinical signs. Crypto can present as other disease like Salmonella and E. coli. Definitive diagnosis can be made with either Giemsa or acid-fast stain. 

Treatment:

No treatment is available for Crypto for calves or people. Supportive treatment is often required. 

Crypto in Cattle:

In a study by Atwill et al. 92% of calves 7-21 days old were actively shedding oocysts in their feces. This is why calves are not cute. Repeat it out loud, Calves-Are-Not-Cute! They are diarrhea making machines in the waiting. Never touch a calf without gloves, and always practice strict biosecurity when handling calves. 

Let’s get rid of the term ‘borderline personality disorder’

The psychological diagnosis of Borderline Personality Disorder (or BDP) continues to be one of the more heavily debated of the psychological disorders.  The straight-up truth, however, is that it’s a full on pejorative label with stigma that all too often causes clinicians to view borderline clients in a negative and resentful fashion.  The significant majority of people identified as borderline are women and the diagnostic criteria reflects a largely male-oriented ideas of healthy psychological functioning.

It can be true that psychotherapy with borderline clients can often be extremely difficult and arduous and it is not uncommon for therapists to feel exhausted and manipulated by their borderline clients.  Although I feel that the specific ways in which BPD is conceptualized and understood often contributes to this negative outlook.

Psychological theorists, such as Judith Herman, Basil Van der Kolk  and many others, argue that BDP is often better understood as a ‘complex’ form of posttraumatic stress disorder (PTSD). Complex PTSD is a more pervasive and ingrained form of chronic difficulties with stress and anxiety that stem from significant experiences of trauma.  Many of the symptoms entailed in complex PTSD can look very similar to the clinical presentation of BDP.

The idea of seeing BPD as a complex form of PTSD is supported by multiple research findings that have found that a significantly high percentage of people diagnosed with BPD have histories of being victims of substantial traumas (Courtois, 2009; Van der Kolk et al., 2006; Driessen et al., 2000; Zanarini et al., 1997; Ogata et al., 1990).

A study reported by Zanarini et al. (1997), for example, looked a large sample of individuals diagnosed with BPD and found that a significant majority of these people had experiences with sexual abuse at some point during their childhoods. Based on these results, and the results of additional studies, Zanirini and her colleagues concluded that severe experiences of trauma appear to be a substantial etiological factor in most cases of BPD.

Judith Herman (1997) notes that identifying someone as being the victim of a trauma tends to elicit a more sympathetic reaction from psychotherapists and other mental healthcare providers. That is to say, a therapist who sees her client as having trauma-related difficulties is less likely to feel annoyed and resentful toward the client as opposed one who is identified as borderline. Complex PTSD is simply a more compassionate diagnosis… one that fosters a greater degree of understanding and empathy (factors that are often essential if a treatment is going to be effective).

Research reported by Courtois et al. (2009) and Van der Kolk et al. (2006) found that treatments that are based on a primary diagnosis of Complex PTSD are substantially more effective and successful compared to those based upon a primary diagnosis of BPD.  Considering that these two diagnostic labels essentially refer to the same condition, it would appear that the therapist’s perspective, compassion, and understanding concerning the root cause of psychological difficulties might often be a key factor in determining a treatment’s ability to succeed and bring about positive results.

Of course there are plenty of people in the professional community who argue against this whole idea, who reject the notion of re-conceptualizing BDP as a complex form of PTSD.  And many would site the neurological evidence gathered that suggests BPD is a largely organic condition caused by subtle neurological abnormalities that lead to greater sensitivity and vulnerability to negative affect.  This idea is largely supported by functional MRI scans that demonstrate significant alterations in the brain scans of subjects identified with BPD versus neurotypical controls.

These opponents argue that the high rates of histories of trauma among those identified with BPD is merely a co-morbid correlation.  Some have even gone so far as to suggest that the increased prevalence of histories of childhood sexual abuse in BPD may itself be a result of these neurological factors. The argument here is that the reduced abilities for impulse control and social inhibition acts as a factor that increase the likelihood that a specific child will be a victim of sexual abuse (Siever, 1997; Siever et al., 1998).  

Yes, you read that right…  These guys actually came up with a neurological version of blaming the victim.  It’s deplorable and the kind of arcane thinking that makes us headshrinkers look like assholes.   

What I feel these arguments fail to take into account, however, is the fact that the brain is a much more plastic and dynamic organ than many give it credit for.  Neurological structures are just as likely to be shaped and affected by our experiences as the other way around.  More current research has shown similar structural abnormalities among combat veterans diagnosed with PTSD.  This shows that traumatic experiences can impact on the functioning and even the structural anatomy of the brain. 

And the heightened sensitivity in limbic regions of those identified with PTSD are not all that different compared to similar findings among patients identified with BPD.

Now of course the real problem with re-conceptualizing BPD as complex PTSD is that there are many people diagnosed with BPD who do not have histories of significant abuse and trauma (Zlotnick et al., 2003). When considering this factor, however, it is important to keep in mind that what constitutes a psychological trauma can be an extremely relative and subjective matter.  Physical and sexual abuse is clearly traumatic and it can be easy to understand how such experiences might impact on psychological functioning. Other instances of trauma, however, can be much more subtle and covert, yet nonetheless be just as psychologically damaging.

In my own research (Goldblatt et al., 2003), my colleagues and I found that children who were neglected and who were separated from primary attachment figures were indistinguishable from children who had experienced severe physical and/or sexual abuse on a number of empirical rating scales. 

These results, coupled with the results of similar studies (Bradley, 2000; Salzman et al., 1997; Van der Kolk, 1994) indicate that neglect and attachment difficulties can be just as traumatic and psychologically damaging as childhood experiences of sexual and/or physical abuse.

What this indicates is that people diagnosed with BPD who do not have histories of severe childhood trauma may still be understood as possibly experiencing a complex form of PTSD.

With the publication of the new Diagnostic and Statistical Manual of Mental Disorders (the DSM-5), Complex PTSD has been recognized as an official diagnostic label.  Unfortunately, the research has found that the inclusion of this disorder has not correlated with a reduction of cases where patients are identified as BPD.  There are a number of factors that may be contributing to this finding… not the least of which being that, as a new diagnosis, clinicians might shy away from utilizing Complex PTDS for worries that insurance providers will reject reimbursement claims.  

Hopefully things will change soon and we will see less and less cases of BPD.  We’ll see…




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☠Poisons! ☠

Firstly, what is a poison?

A poison is a chemical which is capable of producing an unwanted effect.

There are many things that are poisonous to our pets that we would not expect, especially things that we love, such as lilies and chocolate which are potentially fatal to our furry friends. 

In this post i shall list some common poisons that are come across in the veterinary practice and the first clinical signs they present. 

Paracetamol Toxicity
In dogs doses over 20mg/kg are considered toxic.
In cats all doses are considered toxic. 

Clinical signs:(usually seen within one hour of ingestion)

  • Vomiting
  • Depression
  • Cyanosis
  • Dyspnoea
  • Peripheral oedema
  • Anaemia
  • Icterus (jaundice)

Ibuprofen toxicity
Doses of more than 50mg/kg are considered toxic.

Clinical signs:(within 2-4 hours)

  • Nausea
  • Abdominal pain & anorexia, then vomiting & diarrhoea
  • In severe cases: seizures, ataxia, coma & shock.

*Also remember that the packaging can be as harmful as the drug itself!*

Metaldehyde toxicity
More commonly known as slug bait, coming in blue-green pellets.

Clinical signs:(30 minutes-4 hours)

  • Muscle tremors & spasams
  • Hyperaesthesia
  • Convulsions
  • Seizures
  • Coma
  • Death

Vitamin K antagonist (aka rodenticide toxicity)
Can be liquids/pastes/gels/powders/grains/seeds

Clinical signs:(3-7 days)
Persistent bleeding

Permethrin toxicity in cats
Over-the-counter, spot on, flea treatment for dogs which is toxic to cats.

Clinical signs:

  • Tremors
  • Convulsions
  • Seizures
  • Death

Ethylene glycol toxicity
The main substance found in antifreeze which is poisonous to our pets and a main concern in our winter months.

Clinical signs:(in stages)

  • First stage: animal appears drunk, and clinical signs include: ataxia, vomiting, weakness, PUPD, dehydration & hyperthermia
  • Second stage:tachycardia, tachypnoea, pulmonary oedema which can develop into collapse & severe depression.
  • Final stage: oliguria, severe azotemia, vomiting, anorexia, collapse, severe depression & death.

Grape toxicity in dogs
Many people dont realise that grapes are in fact toxic to their pet dogs!

Clinical signs:

  • Vomiting
  • Lethargy
  • Depression
  • Inappetence
  • Oliguria
  • Azotaemia
  • Metabolic acidosis

Theobromine toxicity in dogs
Aka chocolate!

Clinical signs:(within 4 hours-24 hours)

  • Vomiting
  • Abdominal pain
  • PUPD
  • Restlessness
  • Excitability
  • Salivation
  • Ataxia
  • Excessive panting
  • Tachycardia

and finally….

Lily toxicity in cats

Clinical signs:

  • Vomiting
  • Inappetence
  • Depression
  • Renal failure

The morgue is only a side job. Sherlock hasn’t realised because Sherlock is an idiot - well, truth be told, partly because she’s clever enough to stay out of his way whenever he visits, but mostly because he’s an idiot who should see the connection between Mark Hooper, morgue doctor, and Mrs Harper, woman in charge of the London Free Hospital. 

Sherlock is an idiot. A smart idiot, an idiot with occasionally very sharp insights, but an idiot nevertheless.

James Moriarty, however, is not.

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