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C. Domenik. Emporia State University.

Accepting Anxiety with Love It may seem rather counterintuitive discount 75mg clopidogrel overnight delivery, but accepting your loved one’s battle with anxiety is one of the most useful attitudes that you can take order clopidogrel visa. In other words purchase discount clopidogrel on line, whenever you discuss your loved one’s anxiety or engage in any effort to help cheap clopidogrel on line, you need to appreciate and love all your partner’s strengths and weaknesses. If perfect people even existed, we can only imagine that they would be quite boring. Besides, studies show that people who try to be perfect more often become depressed, anxious, and distressed. You need to accept and embrace both the possibility of productive change as well as the chance that your partner may remain stuck. Accepting your partner is especially important when your efforts to help ✓ Result in an argument ✓ Seem ineffective 278 Part V: Helping Others with Anxiety ✓ Aren’t well-received by your partner ✓ Seem merely to increase your partner’s anxiety even after multiple expo- sure trials What does acceptance do? Acceptance allows you and your loved one to join together and grow closer, because acceptance avoids putting pressure on the one you care about. This message frees your loved one to ✓ Take risks ✓ Make mistakes ✓ Feel vulnerable ✓ Feel loved Change requires risk-taking, vulnerability, and mistakes. When people feel that they can safely goof up, look silly, cry, or fail miserably, they can take those risks. Giving up anxiety and fear takes tremendous courage in order to face the risks involved. Letting go of your need to see your partner change helps bol- ster the courage needed. When you take on the role of a helper, it doesn’t mean that your worth is at stake. Chapter 19 Recognizing Anxiety in Kids In This Chapter ▶ Seeing what’s making kids so scared ▶ Knowing when to worry about your kids’ anxiety ▶ Recognizing the usual anxieties of childhood ▶ Looking at the most common anxiety disorders among kids any adults can recall childhood as being a time of freedom, explora- Mtion, and fun. Not too many years ago, kids rode bikes in the street and played outside until dark. Now, anxious parents wait with their children at bus stops until they’re safely loaded. In this chapter, you discover the dif- ference between normal and problematic anxiety in kids. We explain that some childhood fears are completely normal, while others require interven- tion. If you’re concerned about a particular child, we urge you to seek professional diagno- sis and treatment. Numerous studies confirm this alarming development, but one in particular is a shocker. Psychologist Jean Twenge compared symptoms 280 Part V: Helping Others with Anxiety of anxiety in today’s kids with symptoms in seriously disturbed kids receiv- ing hospital treatment in 1957. She reported in the Journal of Personality and Social Psychology (December 2000) that boys and girls today report a greater number of anxiety symptoms than psychiatric inpatient children in 1957. The statistics are bad enough in their own right, but when you consider the fact that anxiety disor- ders often precede the development of depression later on, it raises concerns that the consequences of childhood anxiety could worsen in the years to come. Of course, we all know the complexities and tensions of the world today — longer work hours, rapidly developing technologies, violence on television, and even terrorism. We also suspect that certain types of parenting hold par- tial responsibility, as we discuss in Chapter 20. For the moment, what you as a parent need to know is how to distinguish the normal anxieties of childhood from abnormal suffering. Realize that the vast majority of kids feel anxious at various times to one degree or another. After all, one of the primary tasks of childhood is to figure out how to overcome the fears that life creates for everyone. Successful resolution of those fears usually results in good emotional adjustment. You just need to know whether your children’s fears represent normal development or a more sinister frame of mind that requires help. Look at Table 19-1 to get an idea of the anxiety that you can expect your children to experience at one time or another during their youth. Anxiety Problem When Anxiety Is When Anxiety Should Go Normal Away Fear of separation Common between If this continues with no from mother, father, or the ages of 6 months improvement after 36 to 48 caregiver and 24 months. Chapter 19: Recognizing Anxiety in Kids 281 Anxiety Problem When Anxiety Is When Anxiety Should Go Normal Away Fear of unfamiliar Common from age 2 If this continues without peers until around 3 years showing signs of reduc- old. Fear of animals, dark- Common between If these fears don’t start to ness, and imaginary ages 2 and 6 years. School phobia Mild to moderate This should decline and school or day-care cause no more than minimal phobia is common problems after age 6. A brief from ages 3 to 6; it reemergence at middle can briefly reappear school is okay, but it should when moving from quell quickly. Fear of evaluation by This fear almost It should gradually reduce others defines adolescence. But Most teens worry it’s not uncommon for it to a fair amount about last through the late teens. Table 19-1 gives you some general guidelines about so-called normal child- hood fears. However, independent of age, if fears seem especially serious and/or interfere with your child’s life or schoolwork in a major way, they may be problematic and warrant attention. In addition, other anxiety problems we describe in the section “Inspecting the Most Common Childhood Anxiety Disorders,” later in this chapter, are not particularly normal at any age. If you have any doubts about the seriousness of your children’s anxiety, you should consider a professional consultation. A mental-health counselor or your pediatrician should be well-equipped to handle your questions, quite possibly in a single visit. Anxiety problems sometimes predate other emo- tional difficulties, so you shouldn’t wait to get them checked out. By the time a outgrow sleep disorders, such as bedwetting, child is a teenager, it usually disappears. But then again, because children Sleep terror, especially strange and frighten- don’t remember it, sleep terror usually doesn’t ing to parents, is relatively common, occurring cause the children who have it any daytime among 1 to 6 percent of all kids; the incidence distress. Sleep hood of sleep terror, so parents should make terror tends to present itself about an hour and sure their children get enough sleep. The child typically sits may also contribute to sleep terror, so parents up suddenly and screams for up to half an hour. Children Inspecting the Most Common Childhood Anxiety Disorders Some fear and anxiety are normal for kids. However, other types of anxiety, though not always rare, do indicate a problem that you should address. We briefly review the more common types of problematic anxiety in kids in the following sections. Leaving parents: Separation anxiety disorder As we show in Table 19-1, kids frequently worry about separations from their parents when they’re as young as 6 months to perhaps as old as 4 years of age. The good news is that a large percentage of those with separation anxiety disorder no longer fulfill the diagnostic criteria for the disorder after three or four years. The bad news is that quite a few of these kids go on to develop other prob- lems, especially depression. For that reason, we suggest prompt intervention if it persists longer than a month or two and interferes with normal life. The following story about Tyler and his mother Julie illustrates a typical presentation of separation anxiety in the form of a school phobia. Note that school phobia often also includes an element of social phobia (see the sec- tion “Connecting with others: Social phobia” later in this chapter). The doctor encourages Julie to send Tyler to school and warns that if she doesn’t, Tyler’s behavior is likely to escalate. Tyler suffers from school phobia, a common but serious childhood anxi- ety disorder involving anxiety about both separation from parents and social worries. Most school counsel- ors have had lots of experience in dealing with school phobias. The parent then speaks to the child for school phobia involves getting the child back only an agreed-upon two minutes. Children with encouraged to save the pass for times of great school phobia often have parents who are distress and praised when he doesn’t use the slightly anxious themselves and care deeply pass at all during a day. The first step is to convince the This pass, allowing a parental phone call, grad- parents that they must be firm in their commit- ually fades to one call every other day, one call ment to return the child to school.

To be able to develop a plan for diagnosis and treatment of salivary gland tumors and of primary hyperparathyroidism buy clopidogrel 75mg low cost. He noted a lump in the ante- rior neck while shaving a week ago; the lump is not painful or tender and has not changed order clopidogrel on line amex. On examination clopidogrel 75 mg free shipping, you find a 2-cm-diameter lump just to the left of the midline discount clopidogrel 75mg online, at the anterior margin of the sternocleidomastoid muscle. Agnese History and physical exam Intraoral, Neck pharyngeal, nasal Upper neck Mid-neck Supraclavicular See Algorithm Thyroid See Algorithms See Algorithm Biopsy ± 11. Introduction Problems presented that are centered in the region of the head and neck are best addressed while simultaneously considering the regional anatomy (which is reliable, with minimal anatomic varia- tion between patients) and the patient’s medical and social history. For example, the patient in the case presented above stated that he never smoked and that he drank only an occasional glass of wine. There is a close relationship of high alcohol intake or the use of smokeless tobacco with cancers of the oral cavity and pharynx, and there is a close relationship of tobacco smoking and alcohol intake with cancers of the esophagus and the entire respiratory tract. The patient in our case would not be expected to have a cancer primary in any of these areas, given his social history. Risk Factors Tobacco, in its various forms, is a risk factor for the development of head and neck cancer. Head and Neck Lesions 179 tobacco, and snuff (often referred to as “snoose” in the western states), which is held against the cheek or gums. Betel nut chewing, common in the western Pacific basin and South Asia, also is associated with increased risk. Most cases of head and neck cancer are associated with a significant history of alcohol consumption coupled with a history of tobacco use. Radiation therapy for acne or skin warts can be followed by skin or thyroid cancers years later. History Important points to elicit in the history of the patient presenting with a mass in the head and neck region are: • the exact location of the lesion • the length of time the lesion has been present • the rate of growth of the lesion: rapid enlargement implies infec- tion or malignancy • the presence of pain or tenderness: cancer usually is not painful unless there is a superimposed infection or nerve invasion • the presence of an unpleasant odor: bacterial tonsillitis, a foreign body in a child’s nasal passage, and squamous cell carcinoma of the tonsil or base of tongue with superimposed bacterial infection all are noteworthy for the associated odor • history of difficulty swallowing • painful or tender persistent lesion in the mouth • referred pain to the ear • hoarseness • weight loss • history of radiation exposure. Specific questions regard- ing family members with goiter, multiple endocrine neoplasia syn- drome, or a high incidence of skin cancers should be asked. In addition to a history of the use of tobacco and alcohol, a history of the use of other nonprescription substances should be sought. The patient in our case was asked about these points, but nothing contributory was found. This was a neck lump without symptoms, dis- covered suddenly during a morning shave. On the scalp, epidermal inclusion cysts (known as “wens”) easily can be appreciated; a puncta often is not visible, and skin color is normal. A horn-like, hard little lesion that can be torn off, producing a shallow ulcer, is referred to as actinic keratosis. Patients with these lesions are managed appropriately by referral to a dermatologist or head and neck surgeon for treatment. Skin lesions that have changed during a period of observa- tion, have irregular borders, display variegated pigmentation, or bleed when rubbed must be referred for excision or biopsy. These lesions are called leukoplakia, and a small percentage subsequently develop cancer. Cancers of the gums, tonsillar pillars, and inner surfaces of the cheeks generally are redder than the adjacent surfaces. A patient who seems sick and shows a swollen tonsil near the midline may have a peritonsillar abscess, which requires urgent drainage. Brown patches on the lips signal Peutz-Jeghers syndrome, associ- ated with intestinal polyps that can bleed or obstruct. Skin tumors of various size consisting of tiny blood vessels, hemangiomas, can be found anywhere in the head and neck region. Epidermal inclusion cysts or sebaceous cysts commonly are found behind the lower exter- nal ear, in areas of acne activity, the posterior neck, and the earlobes (especially at the site of skin or ear piercing). The pink or red skin blotches on sun-exposed skin may be malignant or premalignant and generally require diagnosis and possible treatment from a specialist in skin conditions. Darkly pigmented spots or skin blotches that leave a gray, roughened zone when the surface is lightly scraped are sebor- rheic keratoses, related to skin aging. Cervical lymph nodes that are obvious on inspection or palpation mandate a complete examination of the head and neck. A firm uni- lateral neck mass in an adult is cancer until proven otherwise (see Algorithm 11. Many of these are cervical metastases from squamous cell carcinoma of the head and neck. Deviation of the tongue to the side of the lesion may be appreciated when the patient protrudes the tongue, suggesting 12th cranial nerve invasion by cancer. A painless, hard mass in the lower neck in a patient who lives in crowded conditions or is immunocompromised, with or without another known to have tuberculosis, may be scrofula, a tuberculosis lymph nodal mass. A lump in the upper midline of the anterior neck may be a thy- roglossal duct cyst (see Algorithm 11. If located further up, under the chin, it will be an enlarged submental lymph node. If you stand to the side and ask that the tongue be put out, elevation of this lump with tongue protrusion is diagnostic of a thyroglossal duct cyst. Branchial cleft cyst presents at the anterior border of the sternoclei- domastoid muscle or just in front of the external ear’s tragus. When inspecting the thyroid, try sitting lower than the patient, with your eyes at the level of her/his midneck, using some light from the side. Head and Neck Lesions 183 thyroid slides up and down and the thyroid nodule or multinodular goiter easily is seen. Palpation A thyroid nodule often can be appreciated moving up and down under the sternocleidomastoid muscle, as you palpate more deeply lateral to the trachea. Enlarged lymph nodes tend to be found along the course of the jugular vein and are termed high-jugular lymph nodes when located in the upper neck, below the angle of the jaw. Firm, nontender masses in the neck that are not easily moved are likely cancer metastatic to cervical lymph nodes. Infections of the tonsils or teeth also can result in enlargement of neck lymph nodes, but these nodes are tender. When cancer metasta- sizes to the upper jugular nodes, the most common primary sites are the base of the tongue, the nasopharynx, and the tonsillar areas. Cancer metastatic to mid-jugular nodes—lymph nodes in the central lateral neck under the muscle—most commonly originates from the thyroid lobe on that side. Supraclavicular lymph node metastases generally are from cancer sites below the clavicles. Keep in mind, however, that lung cancer can and does spread anywhere (see Algorithm 11. Palpation of the thyroid gland is best performed by facing the patient, placing the index finger on the thyroid cartilage (Adam’s apple) to stabilize it while curling the fingers of the opposite hand around the sternocleidomastoid muscle, resting the thumb on the thyroid isthmus. When the patient is asked to swallow, the thyroid lobe slips up and down between your fingers and thumb, allowing you to appreciate a nodule in that thyroid lobe. A moistened, gloved finger gently sweeps over the gum surfaces, the floor of the mouth, and the tongue, searching for rough or tender areas. With the patient breathing through the mouth, one quickly can sweep across the base of the tongue to the epiglottis. Bimanual examination especially is useful for the floor of the mouth and can be used for cheek surfaces and for the tongue. Special Examination Techniques Special examination techniques are performed by surgical oncologists and head and neck surgical specialists. Fiberoptic laryngoscopes are passed through the nose for direct examination of the vocal cords and nearby areas. A complete examination, searching for a primary cancer site, requires general anesthesia. The examination relies on the use of fiberoptic instruments to look into and at all surfaces that can be reached, 184 J. Agnese including the nasopharynx and sinuses, and the performance of appropriate biopsies. Esophagoscopy and bronchoscopy are added when the primary cancer site has not been found: about 3% of patients with metastatic cancer found in a cervical lymph node will have a final unknown primary classification. Adenocarcinoma diag- nosed by cervical lymph node biopsy indicates the need for further studies, possibly including mammography and endoscopy. Ultrasound can deter- mine whether a lesion is cystic or solid: a thyroid lesion demonstrated on ultrasound is benign if it is entirely cystic.

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Amniotic fluid culture not useful for determining when the mother might Immunology/Correlate laboratory data with have been infected generic 75 mg clopidogrel. The courier placed the whole technologists who performed the tests blood specimen in an ice chest for transport clopidogrel 75 mg online. Order a new lot of both kits and then retest on this specimen generic clopidogrel 75 mg online, no β-γ band is seen in the serum the new lots protein lane purchase clopidogrel 75 mg mastercard, and the IgM lane is very faint. Refer the discrepant specimens for testing by rheumatoid factor on this specimen was negative. Nothing’s wrong with our laboratory; the patient had an infection 2 weeks ago that has cleared up Answers to Questions 22–24 B. Something’s wrong with our laboratory—we likely mislabeled one of the specimens; please 22. You will run a second specimen using a precipitated during the courier ride and was thus 2-mercaptoethanol treatment that will in the clot when the laboratory separated the eliminate IgM aggregates and allow for serum. Te physician should redraw another specimen at low levels following a vaccination for up to from the patient and this time separate the serum 1–2 weeks. Thus, patients who have received a from the clot in his office before sending the second injection of hepatitis B vaccine may have specimen in by courier anti-hepatitis B surface antigen and detectable Immunology/Correlate laboratory data with antigen for a brief period of time. This has been physiological processes/Specimen integrity/3 reported more frequently in dialysis and pediatric 23. D In this situation, you have already tested the Te physician suspects a laboratory error. You could perform clinical chart reviews hepatitis B booster vaccination and could have as an alternative, but obtaining that data would be these results difficult and much of it may be subjective. Clinical Diagnostic Immunology: Protocols in Quality Assurance and Standardization. Polymerase chain reaction biological characteristics/Genetics/Rh/2 Blood bank/Apply knowledge of laboratory operations/Genetics/1 Answers to Questions 1–5 2. In addition to Kell, Blood bank/Apply knowledge of fundamental dosage effect is seen commonly with antigens M, N, biological characteristics/Genetics/Kell/3 a b a b S, s, Fy, Fy, Jk, Jk, and the antigens of the 3. Which of the following describes the expression of are not clearly discerned; however, nucleoli may be most blood group antigens? B Linkage disequilibrium is a phenomenon in which alleles situated in close proximity on a chromosome 11. Indirect/secondary/second order Blood bank/Evaluate laboratory data to verify test results/Genotype/Paternity testing/2 4. Te heterozygous population of one allele are contained in the rabbit polyspecific antihuman B. Te homozygous population of one allele globulin reagent for detection of in vivo C. In this type of inheritance, the father carries the Blood bank/Apply knowledge of fundamental trait on his X chromosome. X-linked recessive used in population genetics to determine the Blood bank/Apply knowledge of fundamental frequency of different alleles. IgM antibodies are larger molecules and have the An example of this type of inheritance is the Xga ability to bind more antigen blood group. A An IgM molecule has the potential to bind up to readily to bind more antigen 10 antigens, as compared to a molecule of IgG, C. B An anamnestic response is a secondary immune decreases the zeta potential, allowing antibody and response in which memory lymphocytes respond antigen to come closer together? Anaphylactic Blood bank/Apply knowledge of fundamental biological characteristics/Antibodies/1 4. An A2 person may form anti-A1; an A1 person Te crossmatch was run on the Ortho Provue and will not form anti-A1 yielded 3+ incompatibility. A2 antigen will not react with anti-A from a antigen nonimmunized donor; A1 will react with any B. Te patient has an antibody to a high-frequency anti-A antigen Blood bank/Apply knowledge of fundamental C. Te patient is an A1 with anti-A2 Blood bank/Apply principles of special procedures/ 2. Te patient may be a Bombay A person who is group A may form anti-A, but an 2 1 D. Which typing results are most likely to occur when a patient has an acquired B antigen? Anti-A 4+, anti-B-3+, A1 cells neg, B cells neg the discrepancy is in forward grouping. Anti-A 3+, anti-B neg, A1 cells neg, B cells neg washed red cells at room temperature with anti-A C. Anti-A 4+, anti-B 1+, A1 cells neg, B cells 4+ and anti-A,B will enhance reactions. Which blood group has the least amount of This may be indicative of an acquired antigen. A1 caused by a mistyping or an antibody against Blood bank/Apply knowledge of fundamental antigens on reverse cells. Wash the cells with warm saline, autoadsorb the autoantibody, allowing a valid forward type to be serum at 4°C performed. Retype the sample using a different lot number washed cells until the autocontrol is negative. B All negative results may be due to weakened Blood bank/Evaluate laboratory and clinical data to antigens or antibodies. Which of the following results is most likely carbohydrate that reacts with: discrepant? A stem cell transplant patient was retyped when Blood bank/Evaluate laboratory data to make she was transferred from another hospital. Patient cells: Anti-A, neg Anti-B, 4+ Answers to Questions 12–17 Patient serum: A1 cells, neg B cells, neg 12. Weak subgroup A subgroups may fail to react with anti-A and require Blood bank/Evaluate laboratory data to make additional testing techniques (e. C The reverse typing should agree with the forward for the following typing results? A positive reaction is expected Patient cells: Anti-A, neg Anti-B, neg with A1 cells in the reverse group. A 61-year-old male with a history of multiple Answer to Question 18 myeloma had a stem cell transplant 3 years ago. Typing results must rely on the patient history of donor type and reveal the following: recipient type, and the present serological picture. A complete Rh typing for antigens C, c, D, E, and Answers to Questions 1–5 e revealed negative results for C, D, and E. A This individual has the D antigen and is classified as Blood bank/Apply knowledge of fundamental Rh positive. Any genotype containing the D antigen biological characteristics/Rh typing/1 will be considered Rh positive. If a patient has a positive direct antiglobulin test, types contain the c antigen and could not be used should you perform a weak D test on the cells? Yes, Rh reagents are enhanced in protein media result from a larger quantity of precursors being Blood bank/Apply knowledge of fundamental available to the D genes because there is no biological characteristics/Rh typing/3 competition from other Rh genes. Most weak D individuals make anti-D agglutination usually requires a 37°C incubation C. Dce/dce both may be conducted at room temperature Blood bank/Evaluate laboratory data to verify test with no special enhancement needed for reaction results/Rh system/Paternity testing/2 Blood bank/Apply knowledge of fundamental biological characteristics/Rh system/1 Answers to Questions 6–11 7. What is one possible genotype for a patient who designation is not noted in the reporting of the develops anti-C antibody? B The genotype rr (dce/dce) lacks D, C, and E antigens Blood bank/Apply knowledge of fundamental and would be suitable for an individual who has biological characteristics/Rh typing/2 developed antibodies to all three antigens. A patient developed a combination of Rh most common Rh-negative genotype and is found in antibodies: anti-C, anti-E, and anti-D.

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