By R. Jaroll. Howard University. 2019.

Status epilepticus Management This is defined as a prolonged single attack or continuing With a first seizure generic naprosyn 250mg free shipping, it is important to exclude any under- attacks of epilepsy without intervals of consciousness cheap naprosyn 500 mg line. Sodium valproate Gabapentin r Lorazepam or diazepam are first-line treatment Lamotrigine Topiramate r If no response discount 500 mg naprosyn amex, intravenous phenytoin loading dose Tiagabine Levetiracetam of 15 mg/kg is given. However, if Neurosurgery is rarely undertaken except in selected attacks only occur whilst asleep and this pattern is es- patients, with persistent, frequent seizures where there is tablished for 3 years, patients can drive even if seizures a significant adverse impact on quality of life, with poor continue. Proce- injury, stroke, cranial surgery but excluding drugs or al- dures include local resection, lobectomy, hemispherec- cohol, the suspension may be shorter. The management of epilepsy should include the discussion of social is- Acute confusional state (delirium) suessuchassupportathome,relationships,employment andpsychologicalissuessuchasdepression. Womenwho Definition wish to become pregnant need special advice, but there Rapid onset of global but fluctuating confusion with an is no reason why they should not have children. There underlying toxic, vascular, ictal (seizure) or metabolic are support groups available. Chapter 7: Disorders of conciousness and memory 311 Aetiology Adetailed history including pre-morbid cognitive state, r Predisposing factors: The very young and very old, alcohol and drugs is essential, fluctuation helps sep- hearing loss or visual difficulty, those with diffuse arate delirium from dementia, examination should brain disease such as dementia or taking drugs with look for focal neurological signs and any evidence anticholinergic properties such as tricyclic antidepres- of other illness. Consider saving r Disorientation and impaired conscious level – urine for toxicology screen. Management r Motoractivity may be increased but is often purpose- r Detection of the underlying cause of the confusional less. Severe cases may require benzodiazepines, Toxic Alcohol intoxication, withdrawal haloperidol or one of the newer anti-psychotics such Drugs Prescribed/illicit drugs, including as risperidone or olanzapine. The prognosis is dependent Hepatic failure on the underlying cause and co-morbid features. Hypoxia Hypoxia and/or hypotension Vitamin deficiency Vitamin B12 Thiamine (Wernicke–Korsakoff) Coma Intracrania Definition Trauma Head injury Coma is a state of unrousable unconsciousness. Vascular Transient ischaemic attack, stroke, any intracranial bleed or space- occupying lesion Aetiology Epilepsy May be post-ictal (after a seizure) or The causes are mainly those of acute confusional state nonconvulsive status (see Table above), although there are other causes as well. No response 1 Best verbal response Management Orientated 5 Following resuscitation treatment of the underlying Disorientated 4 Inappropriate words 3 cause is the main priority. In at-risk patients such as alco- Best motor response holics and in pregnancy, intravenous thiamine should Obeys verbal commands 6 be given prior to any intravenous glucose as there Localizes painful stimuli 5 Withdrawal to pain 4 is a small risk of precipitating irreversible Wernicke– Flexion to pain 3 Korsakoff’s syndrome. No response 1 r Empirical use of naloxone (reverses opiates), flumaze- nil (reverses benzodiazepines) should be considered. Head Injury Definition Head injury is one of the most common causes of death Clinical features and disability in young men, mainly due to road traffic It is important to establish the level of consciousness. Incidence 1 The first priority is resuscitation – stabilise airway, Common;basedonhospitalattendancesandadmissions breathing and circulation and check the glucose level the incidence is ∼250 per 100,000 population. Hypoxia, hypoglycaemia or hypotension are reversible causes of coma and will exacerbate any Age other cause. Chapter 7: Disorders of conciousness and memory 313 r Penetrating trauma: Penetration of the skull by an ex- swelling of the brain. Pathophysiology The pathology of head injury can be divided into two groups: Complications r Primary brain damage: Short term: Vascular, e. Subarachnoid and intracerebral ticularly on the side of the trauma (coup lesion) and haemorrhage may also occur. Long term: ii Diffuse axonal injury due to shearing forces caus- r Posttraumatic epilepsy. Patients r Chronic traumatic encephalopathy (the punch drunk who survive such injury may have severe brain syndrome seen in professional boxers). Ifneckinjuryissuspected,thepatientshould cal treatment, whereas primary brain damage occurs be immobilised until a spinal cord injury or unstable at the time of injury and therefore can only be in- cervical spine has been excluded. Followingtrauma,thebrainismuch Coma Scale, and full neurological and general exami- more susceptible to hypoxia and hypotension due to nation. The decision to admit for observation is based disruption of autoregulation and impaired vascular on the history and assessment at presentation. Osmotic diuretics such as mannitol Clinical features may also be used to reduce brain oedema. In more severe injuries, there is persistent post- mission to intensive care for intracerebral pressure traumatic amnesia. Patients All patients require close monitoring to check for devel- may have other injuries depending on the nature of the opment of complications that require urgent treatment. Over a period of several hours there is oozing of r the patient is difficult to assess, e. Apathy and/or depression are common, there may be Prognosis disturbances of sleep, confusion of day & night, with Recovery may take weeks to months. Other neurological signs with a persisting disability or impairment is 100 such as hemiparesis, seizures tend to occur very late in per 100,000. Generally, in the early stages, the patient is aware of a loss of their memory and may become very frus- Dementia trated and anxious. They lose the ability to function in daily life grad- Definition ually, and in later stages they become more apathetic, Asyndromeofacquiredcognitiveimpairment,withpro- with little spontaneous effort and therefore require full gressive global loss of cognitive function in the context personal care such as feeding, washing, dressing and of normal arousal. Acollateral history from a relative or close carer who Incidence has known the patient for a long time is essential. The 1% of those aged 65–74 years, 10% of those over 75 and carer is often the one most emotionally affected by the 25% of those over 85 years. Aetiology There are numerous causes of dementia, including Investigations r Alzheimer’s disease (most common >60%). These are to exclude any treatable causes of chronic con- r multi-infarct dementia caused by multiple small in- fusion. Management The specific management strategies are covered under Clinical features specific causes but general treatment includes the fol- See also under specific causes of dementia. Patients may lowing: have impairment of the following cognitive functions: r Multidisciplinary assessment. Chapter 7: Disorders of conciousness and memory 315 r Antidepressantsmayimprovefunctionallevelinthose r Neurochemical analysis reveals that patients with with low mood. The features are those of dementia, but with an insidious onset and progressive decline in memory and at least one of: Alzheimer’s disease r Dysphasia: Loss in language skills, especially with Definition names and understanding speech. Most common neurodegenerative disorder and cause of r Agnosia: Loss of ability to recognise objects, people, dementia. The onset can be in middle age, but the incidence rises r Disturbance in executive functioning (higher mental with age. Aetiology/pathophysiology r Risk factors include family history, Down’s syndrome Macroscopy and previous head injury.

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Positive views about continually improving road safety may not be supported by what A actually happens buy naprosyn 250 mg on-line. B Government programmes have been unsuccessful in reducing the number of accidents buy generic naprosyn from india. Hospital admissions are a good way of measuring changes in the number of accidents C on our roads naprosyn 500mg for sale. Biology 41 The following organelles are involved in processing amino acids into glycoprotein: 1. A ii and v B ii and iv C i and iii D iii and v E i and iv 46 Which one of the following molecules will contain the greatest number of different elements? Which one of the following pairs of elements is most likely to form a covalent bond? A first = slightly exothermic; second = very endothermic B first = slightly exothermic; second = very exothermic C first = slightly endothermic; second = very exothermic D first = slightly endothermic; second = very endothermic E first = very exothermic; second = very exothermic 64 In the following reactions, which substances are acting as oxidising agents? A 3 only B 1 only C 2 only D 2 and 3 only E none 66 What is the total number of electrons in the ions of sodium chloride? Amines Amides Row 1 Ethanoic acid reacts does not react Row 2 Nitrous acid reacts reacts Row 3 Sulphuric acid does not react hydrolyses A Rows 1 and 2 B None of the rows C Rows 1 and 3 D Rows 2 and 3 E All of the rows 68 Consider the following reactions. Physics and Mathematics 70 In a group of students, exactly 2 are male and exactly 1 study mathematics. The probability that a 5 3 male student chosen at random from the group studies mathematics is p. The transformation R is a rotation about the origin and maps A to B, B to C, C to D, etc. A R R S R S R B R S R S C S R D R S R R E S R R S R S 72 The line L has equation y = 2x - 1. A 2ln y B ln x + 2 ln y C 0 D ln x + ln y E 2 ln x + 2 ln y 74 2 What is the set of values of x for which x < 9 and 2x + 3 ≥ 5? A 1≤ x < 3 B x > 3 C x > −3 D x < −3 or x ≥ 1 E x ≥ −1 o o 75 A block of iron at 100 C is transferred to a plastic cup containing water at 20 C. When a current is passed through mercury under these conditions, which of the following effects will be present? D G T L M N Implications for H ealthcare Leaders American College of Healthcare Executives Management Series Editorial Board Ralph H. For more information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424-9470. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author(s) and do not represent the official positions of the American College of Healthcare Executives, of the Foundation of the American College of Healthcare Executives, or of the Association of University Programs in Health Administration. Copyright © 2003 by the Foundation of the American College of Healthcare Executives. This book or parts thereof may not be reproduced in any form without written permission of the publisher. As few as 5 percent of hospitals have implemented inpatient provider order entry at scale. An estimated 17 percent of primary care providers use a computerized medical record. Such an increase would lead to higher quality, more efficient, and safer healthcare. We must be able to convincingly answer the question posed by solo practitioners, hospitals, and integrated delivery systems, “What’s in it for me? The organization must possess the broad array of assets—for example, leadership, talented teams, and adequate technology— needed to effectively implement these systems. However, the return must be seen as important to the or- ganization, and data must be available from organizations “like us” indicating that the return can be achieved. This vision must energize a wide range of leadership, endure over the course of years, and be of sufficient clarity to guide a range of decisions. Asset development falls squarely on the shoulders of the organization’s administrative and medical staff leadership and its board. The first asset is leadership that is smart, honest, seasoned, and committed and that values the healthy exchange of ideas. They viii Foreword ask hard questions and are pragmatic; they are superb practitioners of the art of the possible. The second asset is the ability to effect change, at times dramatic change, in work processes, culture, and organizational competen- cies. This ability requires developing and communicating a vision, political skill in mobilizing stakeholders, stamina, and the willing- ness to learn. It also means the organizations take steps to mitigate the many factors that often impede their ability to effect change, such as fuzzy goals, poor management of implementations, and failure to put someone in charge. The third asset is prowess in a small number of critical areas of information systems implementation. Superb support is the factor that causes an application to “stick,” to become an integral part of the fabric of practice. Support includes training, responsive enhancements, ongoing communication and discussion of status and problems, and evolution of work and clinical policies and pro- cedures. Workflow must be thoroughly understood; at times the workflow must be reengineered, and at times the application must be reengineered. Solid and effective relationships must be established between information systems professionals and users. This relationship is one of realism about the systems and the changes they will bring and one in which there are shared goals and a mutual interest in learning from each other. Clin- ical information systems must have a technical foundation that is reliable, high performance, secure, supportable, and adaptable. Few things cripple a clinical information system as quickly as a slow or unreliable infrastructure. Limited ability to enhance applications or augment them with new technologies can result in a poor fit be- tween an application and the clinical workflow and in a failure of the application to adapt as organizations and patient care evolve. Poorly Foreword ix designed applications may not weaken as rapidly as an infrastructure that crashes routinely, but they do weaken.

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Common causes include ischaemic heart disease and Ventricular tachycardia hypertension discount naprosyn online. Ectopic beats may arise due to any of Definition the mechanisms of arrhythmias 250 mg naprosyn amex, such as a re-entry cir- Tachycardia of ventricular origin at a rate of 120–220 cuit or due to enhanced automaticity (which may occur bpm cheap naprosyn line. When ventricular ectopic beats occur regularly Ventricular tachycardia is normally associated with un- after each sinus beat, it is termed bigeminy, which is fre- derlying coronary, ischaemic or hypertensive heart dis- quently due to digoxin. Clinical features Patients are usually asymptomatic but may feel uncom- Pathophysiology fortable or beaware of an irregular heart or missed beats. The underlying mechanism is thought to be enhanced On examination the pulse may be irregular if ectopics automaticity,leadingtore-entrycircuitasinothertachy- are frequent. In ventricular tachycardia there is a small (or sometimes large) group of ischaemic or electrically non- homogeneouscells,typicallyresultingfromanacutemy- Investigations r ocardial infarction. Clinical features r Echocardiography and exercise testing may be used The condition is episodic with attacks usually lasting to look for underlying structural or ischaemic heart minutes. Chapter 2: Cardiac arrhythmias 55 compromise of cardiac output overt cardiac failure or Torsades de pointes loss of consciousness may occur. The presenting pic- Definition ture is dependent on the rapidity of the tachycardia and Torsades de pointes or ‘twisting of the points’ is a con- the function of the left ventricle, as well as general con- dition in which there is episodic tachycardia and a pro- dition of the patient (e. Carotid sinus massage may help to to congenital cause, hypokalaemia, hypocalcaemia, anti- distinguish ventricular tachycardia, which does not re- arrhythmic drugs, tricyclic antidepressants or bradycar- spond, from supraventricular tachycardia with bundle dia from the sick sinus syndrome. Low serum potas- It is thought that the long Q–T interval allows adjacent sium or magnesium may predispose to arrhythmias, so cells, which are repolarising at slightly different rates, levels should be checked. The Q–T interval is prolonged by biochemical abnormalities and Complications drugs, and is also prolonged in bradycardic states. Cardiac arrest due to pulseless ventricular tachycardia or ventricular fibrillation. Clinical features It typically recurs in frequent short attacks, causing pre- syncope, syncope or heart failure. Management r Any underlying electrolyte disturbance should be identified and managed. It is now customary to use these in patients Definition known to have a high risk of sudden cardiac death. Chaoticelectromechanicalactivityoftheventriclescaus- ing a loss of cardiac output. Conduction disturbances Incidence The most common cause of sudden death and the most Atrioventricular block common primary arrhythmia in cardiac arrest. Atrioventricular or heart block describes an alteration in the normal pattern of transmission of action poten- Aetiology tials between the atria and the ventricles. Pathophysiology r complete failure of transmission (third-degree heart The underlying electrical activity consists of multiple ec- block). First degree atrioventricular block Definition Clinical features Atrioventricular block describes an alteration in the The clinical picture is of cardiac arrest with loss of ar- transmission of action potentials between the atria and terial pulsation, loss of consciousness and cessation of the ventricles. Management r Early defibrillation is the most important treatment, as the longer it is delayed the less likely reversion to Clinical features sinus rhythm is possible. Patients are usually asymptomatic; however, an irregular pulse is detected on examination. Most commonly every third or fourth atrial Management beat fails to conduct to the ventricle. Ventricular escape may be required either as a temporary measure or beats may be seen. Patients are at risk of progression to third degree heart block, which may present as cardiac syncope. If patients do not return to sinus rhythm or if not associated with myocardial infarction permanent Incidence pacing is indicated. Third degree heart block is complete electrical dissocia- tion of the atria from the ventricles. It may also occur following Cardiac failure, Stokes–Adams attacks, asystole, sudden a massive anterior myocardial infarction and is a sign cardiac death. Rare r In acute complete heart block, intravenous isopre- causes include drugs, post-surgery, rheumatic fever naline or a temporary pacing wire may be used. Block of conduction in the left branch of the bundle of r Broad complex disease is due to more distal disease of His, which normally facilitates transmission of impulses the Purkinje system. The pacing thus arises within the to the left ventricle myocardium giving an unreliable 15–40 bpm rate. In the elderly causes include fibrosis of the central bundle branches (Lenegre’s disease). Clinical features Clinical features r Severity of symptoms is dependent on the rate and re- Most patients are asymptomatic but reversed splitting of liability of the ectopic pacemaker, and whether or not the second heart sound may be observed. Symptoms include those of cardiac block the second heart sound is split on expiration, be- failure, dizziness and Stokes–Adams attacks (syncopal cause left ventricular conduction delay causes the aortic episodes lasting 5–30 seconds due to failure of ven- valvetocloseafterthepulmonaryvalve. Acute left bundle branch block may be a caused by ischaemic heart disease, fibrosis of the bundles sign of acute myocardial infarction (see pages 37–39). Acute onset right bundle branch block may be associated with pulmonary embolism or a Complications rightventricular infarct. Clinical features Management Right bundle branch block is asymptomatic and is often Treatment is not necessary. There is widened splitting of the heart sounds with the pulmonary sound occurring later Right bundle branch block than normal. Definition Investigations Block to the right branch of the bundle of His, which The characteristic RsR’ is seen best in lead V1 and a normally facilitates transmission of impulses to the right late S wave is seen in V6. Aetiology/pathophysiology Right bundle branch block is often due to a congenital abnormality of little significance, but may be associated Complications withatrialseptaldefects. Management ing in a failure to maintain sufficient cardiac output to Treatment is not necessary. The clinical syndrome of heart failure is characterised by breathlessness, fatigue Prognosis and fluid retention. Isolated right bundle branch block, particularly in a young person is generally benign. Concomitant left or Prevalence/incidence severe right axis deviation may indicate block in one of 900,000 cases in the United Kingdom; 1–4 cases per 1000 the fascicles of the left bundle, which can occur as a pre- population per annum. Cardiac failure Aetiology The most common cause of heart failure in the United Heart failure Kingdom is coronary artery disease (65%). Causes in- Definition clude Heart failure is a complex syndrome that can result from r myocardial dysfunction, e.