By R. Nasib. Andrew Jackson University.
Which of the following is the (C) The measurements correlate inversely with recommended course of treatment? Which of the (D) Draw baseline serologic studies for hepatitides B following would warrant initiating such treatment? Multiple when the serology is positive as confirmed by the Western infarct dementia occurs in older people and is associated blot buy top avana now yellow 5 impotence. Fortunately discount top avana master card erectile dysfunction drug companies, early interventional therapy has made it with long-standing hypertension generic top avana 80 mg with visa impotence due to diabetes. Metastatic cancer could likely that fewer patients will develop the aforementioned be confused with the radiographic picture in some cases Acquired Infectious Diseases in Primary Care 187 but would pose the dilemma of accounting for a clinical 13 generic top avana 80mg with amex erectile dysfunction under 30. If the viral load is reported as a low level, 4 to 6 weeks after cessation of symptoms. All other choice is pyrimethamine given 25 to 100 mg daily plus statements regarding the use and applications of viral sulfadiazine given 1 to 1. Candidiasis is highly suggestive of diagnosis with or without corroboratory laboratory evi- immunoincompetence in adults, particularly in the dence. Other indications are the clinical presence of the fol- esophagus, trachea, bronchi, or lungs. The clinical pneumocystis jiroveci pneumonia; and progressive multi- picture does not include a description of herpetic or aph- focal leukoencephalopathy and cerebral toxoplasmosis. Indeed, unless there is a break in the mucosa that exudes blood the risks, even in the vignette presented, are minimal, but into the saliva; thus, the shared toothbrush is a risk. Urine, available as 150 mg lamivudine/300 mg zidovudine, taken saliva, perspiration, and even vaginal secretions normally twice daily for a recommended period of 4 weeks. New York/Chicago : McGraw-Hill/Lange ; nosis of exclusion (see Question 5 and its discussion). Adult acquired immune deﬁciency syn- cognitive changes but motor problems in Alzheimer dis- drome. Breathing appears to be mildly (A) Stage 3 carcinoma of the cervix labored and shallow, but the lung fields are “clear” to (B) Streptococcus pyogenes auscultation and percussion. Of the following that (C) Actinomyces israelii are present in the differential diagnosis of these (D) Staphylococcus aureus symptoms, which one is the most likely? The stools were grayish, (E) Myasthenia gravis turbid, without fecal odor, and voluminous in fluid volume. Cramping was minimal, and he was afebrile, 5 A 50-year-old diabetic man complains of rapidly but the patient was lightheaded when he stood up by developing redness of the right (anatomical) leg over the second day. The man complains of pain (B) Cholera (rice water stools) that extends several centimeters beyond the area of (C) Travelers diarrhea visible inflammation while noting hypesthesia at the (D) Shigellosis dysentery (bloody) viable site. The area is warm to touch and the patient (E) Typhoid fever manifests systemic symptoms consisting of fever (temperature of 100. Her membranes had ruptured about (B) Blood culture 24 hours before her reporting to the emergency (C) Complete blood cell count department of the hospital. Upon examination, you hear a heart mur- macular rash of pink lesions that appears on the mur that was never mentioned in your notes, includ- palms, soles, wrists, forearms, and ankles. He is alert but uncomfortable family in North Carolina from 2 weeks ago until and manifests no neck stiffness. Today, he has also begun to com- an urgent care center 2 weeks ago and was given a plain of headache, cough, and pleuritic chest pain. Complete blood count shows gation, that the young man has been using illicit intra- thrombocytopenia, hyponatremia, and hyperbiliru- venous recreational drugs. Upon examination, he manifests conjunc- shows infectious infiltrates in various places in both tival injection, sore and fissured lips, palmar and lungs. Which of the following sites would be most solar erythema with desquamation of the tips of one likely to be the seat of the infection? He complains also of the (E) Hypertrophic cardiomyopathy recurrence over 4 days of soreness and focal redness on the left side of his nose, manifesting a flame- 12 A 35-year-old woman complains of a rash of variable shaped region of erythema involving the left naris. She had been camping denies sore throat, and a rapid flocculation test for in the New England states and had been in the wil- beta-hemolytic streptococcus is negative. She does not recall any prior skin lesions since the Which of the following is the most likely diagnosis? Examination reveals a general- (A) Scarlatina ized rash of red lesions, some annular, some target (B) Kawasaki syndrome like, some more intense centrally. Which of the fol- (C) Secondary syphilis lowing is the most likely cause of these symptoms? He complains also of (E) Lyme disease Other Infectious Diseases in Primary Care 191 13 Regarding the reemergence of pertussis, each of the (D) Suppressant therapy can reduce the recurrence following is true, except which one? She was recently (D) Timely treatment with macrolide antibiotics discharged from a hospital, with likely diagnosis of reduces the severity and length of the period of Legionnaires disease in the patient. The symp- depicted is typical for actinomycosis with its slow and toms are those of anticholinergic poisoning, and there is a insidious course, characterized by granulomatous spread curare-like effect on the skeletal muscles (i. Dyspnea is due to paraly- “lumpy jaw” but can involve the intestines, and in the sis of the diaphragm and intercostal muscles. Myasthenia gravis smear virtually rules out cancer in a process so far and Guillain–Barré syndrome should be considered, but advanced as that in the vignette. Surgical exploration, probable debri- dement, and biopsy are crucial in the clinical picture 2. Narcotizing soft tissue infection, appreciated results in watery gray stools (rice water stools) and mas- increasingly in the past 10 years, usually begins acutely, sive fluid loss. The fluid loss in full-blown cases is massive, up to 15 L/ Originally thought to be caused by an evolved virulent day and sometimes 1 L/hour, and is the cause of death if strain of beta-hemolytic group A streptococcus, it has fluid therapy is not aggressively pursued. Travelers diarrhea generally causes severe that is most frequently due to Staphylococcus epidermidis, cramps as well as diarrhea for a brief period but not the beta-hemolytic strep, Enterococcus organisms, E. While stool cultures will Proteus mirabilis, Klebsiella pneumoniae, Pseudomonas reveal Vibrio cholerae, confirming the diagnosis, the dis- aeruginosa, and species of Streptococcus, Bacteroides, Pre- ease is caused by the toxin adenylyl cyclase elaborated votella, and Clostridium, as well as anaerobic cocci and thereby. Aerobic and anaerobic organisms may be found in ment (addressing physiological amounts of saline), and combination. Each of the other studies mentioned are the course can be shortened by tetracycline, ampicillin, relevant, but none is diagnostic. It occurs usually quite early after delivery in the fasciitis, is often so devastating in its course, suspicion form of pneumonia but may be expressed in more subtle must yield to surgical debridement. Biopsy permits the clinical form as in this case, with hypotonia and poor diagnosis of the etiologic organisms and of the pathophys- feeding. Botulism is found in essentially three The blanching macular rash evolves into a petechial erup- forms: the foodborne form, as in the ingestion of pre- tion. The cause is Rickettsia rickettsii, passed through the formed toxin in canned, smoked, or vacuum-packed foods, bite of a tick with an incubation period of 7 to 14 days. Con- produced in the gastrointestinal tract of infants, and trary to the implications of its name, 56% of cases occur in wound borne botulism. The latter is found most often in one of five states, North Carolina, South Carolina, Tennes- injection drug users, probably most likely in those cases in see, Oklahoma, and Arkansas. Up to 40% of patients do which the addict has run out of functional surface veins not recall the tick bite. There is a 3% to 5% case mortality, Other Infectious Diseases in Primary Care 193 more likely in elderly and infirm. Diagnosis is made following types: injected pharynx, erythema, swelling by serial serological studies, a process that may take or fissure of the lips, strawberry tongue 2 weeks, or by immunofluorescent antibody. Meningococcemia, because of the serious- verse grooves in the fingernails) ness, must be considered and ruled out. Toxic shock syndrome now occurs as fever is characterized by a rash, but nearly always mani- frequently in non-female menstrual situations as in the fests gastrointestinal symptoms, usually evolving into originally described association with the retained tam- “soupy diarrhea. The vesicular changes of the palms and soles lead to tis is made by spinal tap for identification of Neisseria the well-known desquamation seen in the late stages. Scarlatina may be considered long enough to rule out reserved for pregnant women to avoid tetracycline side quickly because the rash of scarlatina is quite different, effects in the fetus. Although secondary syphilis mani- among the choices that fits the clinical picture presented. Cirrhosis of the agent, perhaps one of several that may engender the vasc- liver is mentioned because of palmar erythema seen in the ulitis that is the essence of the disease. Asians are more face of patients with advanced compromise of liver func- susceptible. Again, however, vesicle formation and desquamation culitides, especially coronary vasculitis that can lead to is not characteristic of such a situation. Roseola affects younger children and is characterized by very high fever for several days 9. Febrile disease associated with a new that breaks precisely as a morbilliform rash appears. The disease is also called toms and persists throughout, as do the Koplik spots that infectious endocarditis to distinguish it from autoim- are most often seen opposite the second molars or in the mune endocarditis. Rubella is also called the “three day mea- valvular heart disease and intravenous drug abuse. How- sles,” and the adenopathy occurs in the retroauricular and ever, neither of the foregoing may be present for there to subocciputal regions. The painful lesions of the fin- A beta-hemolytic streptococcal infection that releases the gers and toes fit the description of Osler’s nodes. With the cervical adenopathy and the stigmata of endocarditis of bacterial endocarditis include desquamation of the fingertips, scalatina must be consid- Janeway nodes (painless erythematous lesions of the ered as well, but can easily be diagnosed as streptococcus palms or soles), splinter hemorrhages of the nails, and disease with the 10-minute flocculation “Rapid Strep” Roth spots (retinal exudates). Erythema infectiosum is “fifth risk for hepatitides B and C because of his drug abuse disease,” occurs in infants younger than 2 years, and is history, and thus they should be ruled out in any febrile known for the slapped cheek appearance, caused by a dif- illness, they do not present with heart murmurs nor are fuse flush as opposed to the other rashes described in this well known for skin lesions. Diagnosis is based on effected a change in the overall concepts of bacterial endo- fever lasting at least 5 days and satisfaction of clinical cri- carditis over the past 30 years. The tricuspid valve is the one most fluid is the standard; type-specific serological testing is often involved in intravenous drug abuse and, as a right- available.
The capacity to formulate internal values and ideals reflects a consideration of one’s self in the context of one’s culture order top avana 80 mg erectile dysfunction drugs list, and the ability to make mindful decisions based on a set of coherent generic 80 mg top avana with amex erectile dysfunction treatment with fruits, flexible buy discount top avana 80 mg online erectile dysfunction and diabetes pdf, and internally consistent Profile of Mental Functioning—M Axis 79 underlying moral principles order discount top avana line impotence meaning. High functioning in this domain requires that one’s moral reasoning be based not only on a set of cohesive core principles, but also on an aware- ness of the impact of one’s moral decisions on others. The capacity for meaning and purpose reflects the individual’s ability to construct a personal narrative that gives coherence and meaning to personal choices, a sense of directedness and purpose, a concern for succeeding generations, and a spirituality (not necessarily expressed as traditional religiosity) that imbues one’s life with mean- ing. High functioning for this capacity entails the ability to think beyond immediate concerns to consider the broader implications of one’s attitudes, beliefs, and behaviors. Empirically Grounded Assessment of M‑Axis Capacities A growing body of research demonstrates that it is possible to assess these 12 com- ponents of mental functioning. To facilitate clinically useful diagnosis and case con- ceptualization, assessment of M-Axis capacities must yield practically applicable results with utility for diagnostic formulation, treatment planning, and treatment implementation, usable by clinicians across orientations. Thus, for each capacity, we provide a list of well-validated clinical tools that can aid in assessment. In general, we favor clinician-rated and performance-based assessment measures, but in many cases self-reports can complement and enrich the data obtained via clinician-rated and performance- based scales. Administration requires at least 1 hour; scoring and interpretation require approximately 2 additional hours. Despite its relevance for the assessment of most of the 12 M-Axis capacities, we have opted not to include spe- cific descriptions of the most relevant Rorschach categories for each mental capacity because its administration, scoring, and interpretation are quite complex and require considerable formal training and experience. To obtain a more nuanced and detailed picture of a patient’s functioning in each capacity, these empirically validated assessment instruments can and should be inte- grated with information obtained in other ways (e. For a broader array of assessment instruments and strategies for integrating information derived from these instruments, see Chapter 15. Capacity for Regulation, Attention, and Learning The capacity for regulation, attention, and learning encompasses the range of consti- tutional and maturational contributions to an individual’s overall psychological func- tioning, as manifested in the domains of auditory processing and language, visual– spatial processing, motor planning and sequencing, and sensory modulation. Other processes involved in this capacity include executive functioning, attention, intelli- gence, processing of affective and social cues, and memory in its various forms (short- and long-term, semantic, autobiographical/episodic, and implicit/nondeclarative). Taken together, these mental functions enable people to attend to and process internal and external information, regulate the experience of self and the environment, filter extraneous input from consciousness when appropriate, and learn from their experi- ences to enhance adaptation and coping. In rating this capacity, one should note that variations in genetic predisposition, temperament, and neurobiological substrates of regulation, attention, and learning are modified by a person’s social and emotional context throughout development, begin- ning with early child–caregiver interactions. The individual develops characteristic predispositions and biases in attention and executive functioning as a result of these (and other) early experiences, and these predispositions and biases will be evident in how he or she interacts with others and the external environment later in life. More- over, this capacity can be influenced by affect states the individual is experiencing at the moment (anxiety, distress, fear, etc. This capacity differs somewhat from others on the M Axis, in that ratings of the patient’s functioning in this domain are strengthened by (and in some cases require) external corroboration. Although the clinician’s initial conclusions about the patient’s capacity for regulation, attention, and learning may be based primarily on self-report and referral data, when difficulties are documented in the patient’s file, in life history records, or by knowledgeable informants (e. Profile of Mental Functioning—M Axis 81 Rating Scale For this and each of the other M-Axis capacities, a 5-point rating scale, in which each mental function can be assessed from 5 to 1, is provided in Table 2. Descriptions of the anchor points for levels 5, 3, and 1 for each capacity are provided in the text. The individual is appropriately focused, well organized, and able to adapt and learn from experience, even under stress. There is a good ability to express thoughts, affects, and other inner experiences, both verbally and nonverbally. Memory, atten- tion, and executive function are all functioning at a high level, and well integrated. The individual is generally focused, organized, and able to adapt and learn when motivated. When not fully engaged, the person may show a moderate decline from customary functioning. Even when functioning optimally, the individual at this level can attend and focus only for relatively short periods and to a limited degree. Under stress, there may be a significant decline, with emergence of problems in language, information processing, and/or executive function. The individual’s attention is fleeting, and he or she is generally incapable of remain- ing focused, organized, and attentive. The person may have difficulty adapting to the environment and learning from experience, and may be self-absorbed, lethar- gic, or passive. Most Relevant Assessment Tools A broad array of assessment tools are relevant to assessing regulation, attention, and learning. Among the most important are measures of (1) intelligence; (2) working memory and autobiographical/episodic memory; (3) neuropsychological functioning; (4) learning capacity and learning disability (e. Formal assessment of regulation, attention, and learning differs somewhat from evaluating other M-Axis capacities, in that many clinicians are not fully trained in administering and interpreting cognitive and neuropsychological tests. Moreover, many such measures are revised and updated frequently, requiring continued retrain- ing. We recommend that clinicians with appropriate background and experience administer and score cognitive and neuropsychological tests that fall within their areas of competence. When more specialized interpretation is required, a patient should be referred to an appropriately trained neuropsychologist for more advanced assessment. The tests described below are examples of measures that may be useful in assess- ing regulation, attention, and learning; they are not meant to constitute a comprehen- sive or definitive list. Normed on individuals ages 16–90, it includes verbal comprehension, with subtests of similarities (abstract, associative, and categori- cal reasoning, and verbal concept formation), vocabulary (word knowledge, language 82 I. It provides a brief screening assessment of key areas of cognitive functioning, including attention, short-term memory, orientation, and some basic executive tasks. The participant’s task is to sort two sets of 64 response cards on the basis of shapes, colors, and numbers, which change during the course of sorting. Participants must infer the correct sorting principles through limited feedback from the experi- menter, who says only whether the sorting is correct or incorrect. Scores may be tallied along several dimensions, but the number of categories achieved and the number of perseverative errors are the most commonly reported outcomes (Rhodes, 2004). The 89-item version assesses executive problems within five domains: time management problems, organizational problems, self-restraint problems, self-motivation problems, and emotion regulation problems. Participants rate each item on a 1–4 Likert scale (never, sometimes, often, very often). It has the following subtests: names, belonging, appointment, pictures, immediate story, delayed story, faces, immediate route, delayed route, immediate message, delayed mes- sage, orientation, and date. Performance involves visual–motor response, visual–spatial perception and retention, visual and verbal conceptualization, and immediate memory span (Lezak, Howieson, Bigler, & Tranel, 2012). All formats use cards containing geometric and abstract figures, which the examinee must either construct or recog- nize. Each card is exposed for 10 seconds, after which the examinee draws the figure(s) from immediate memory. The dysexecutive syndrome is a major area of cognitive deficit that may impede functional recovery and the ability to respond to rehabilitation programs. Four subtests measure problem solv- ing, organizing, and planning; conventional scheduling system; supervisory attention system; and assessing real-life behaviors. In terms of construct validity, it is comparable to standard executive tests in discriminat- ing between individuals with and without brain damage (Norris & Tate, 2000). Stroop Color and Word Test The Stroop Color and Word Test (Golden & Freshwater, 2002; Jensen & Rohwer, 1966; Stroop, 1935) is used to determine a person’s capacity to direct attention toward relevant information while inhibiting irrelevant information. The time between presen- tation of the stimulus and behavioral response is measured. There are several test vari- ants in common clinical use, with differences in number of subtasks, type and number of stimuli, times for the task, and scoring procedures. The most widely used version consists of three trials, each with 100 items, presented across 5 columns of 20 items. Capacity for Affective Range, Communication, and Understanding The second capacity reflects the ability to experience, comprehend, and express affects in a way that is appropriate to a particular situation and consistent with one’s cultural milieu. It includes the qual- ity of expression, intentional or unintentional, of inner emotional experiences (i. Very low functioning in this domain can lead to dif- ficulties in identifying, differentiating, and communicating feelings, a lack of imagina- tion, and a constricted, externally oriented thinking style (i. This capacity, largely influenced by early infant–caregiver interactions, is related to social cognition insofar as it allows a person to understand, act on, and benefit from interpersonal interactions. Individual differences in this capacity can be due in part to Profile of Mental Functioning—M Axis 85 cultural background, norms, and experience. In general, these unique patterns should be captured in the narrative characterizing the person. Individuals at this level can use, express, communicate, and understand a wide range of subtle emotions effectively. They can decipher and respond to most emo- tional signals flexibly and accurately, even under stress (e. Affective communication almost always seems appropriate in quality and intensity to the situation experienced in the moment. Individuals at this level seem to experience and communicate a constricted range of emotional states, and/or show difficulty experiencing specific affects (e. They decipher others’ emotional states with difficulty and may respond to emo- tional signals in a dysregulated and asynchronous way, especially when challenged or stressed. Or they may express emotions in an inadequate way, disproportionate to situations and social expectations. Individuals at this level show mostly fragmented, chaotic emotional expressions, or convey little emotion at all (e. Low functioning in this capacity may involve distortion of others’ emotional signals (e. The capacity for affective range, communication, and understanding is covered by the following items: 12. Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, excitement, etc.
Ultrasound beam shape with one focal zone in transmit T and multiple focal zones on receive cheap top avana 80 mg on-line impotence ginseng. Time delays to focus at R1 top avana 80 mg discount erectile dysfunction drugs without side effects, R2 and R3 are switched in when echoes are arriving from those depths trusted 80mg top avana icd 9 code for erectile dysfunction due to medication. By changing the time delays cheap top avana online mastercard impotence at 40, it is possible to focus a the beam on different depths in the tissue. The time delays where w is the beam width at the focus, F is the distance can be rapidly switched from one set to another so that of the focus from the transducer, λ is the wavelength and multiple focal zones can be used in receive, improving the a is the half-width of the transducer aperture. That is, for each Focusing produces a narrower beam than if no focusing transmitted pulse, as echoes arrive from successively were used over a range along the axis known as the focal greater depths, the next set of time delays is switched in zone. For the transmitted pulse wider than if no focusing were to be applied, as the beam itself, only one focal zone can be used, as that focused spreads out more. The stronger the focusing, the narrower pulse travels out to all depths of tissue before it is fully the focal zone, but, in addition, the worse the beam spread attenuated. On the larger scanners it is possible for the user to choose at what depth of tissue to place the transmit focal Electronic focusing zone. Its position is usually shown by a marker down the An ultrasound beam will be focused if all of the wavefronts side of the image. Because the lateral resolution is poorer in the sound wave converge on a single point in space: the outside the focal zone, it is important to ensure that the focal point. This may be achieved by a lens, which refracts focal zone is set to the depth of the target of interest when or bends the wavefronts into such a converging wave. On small portable scanners a weaker fxed focus When a transducer array is used, as is the case in medical (that the user has no control of) is used, giving some imaging, focusing can be achieved electronically by the use improvement in lateral resolution over the central area of of time delays, in a similar manner to electronic beam the image. Time delays are chosen to control when the transmitted pulse reaches each element so that Slice thickness the propagating wavefront forms a converging line along a circle centred on the desired focal point in front of the When viewing an ultrasound image we see a slice through transducer. The slice in the body is called the ing, the peaks and troughs of the received echoes will add scan plane or image plane. It is important to note that the up strongly for echoes arising from the beam directed scan plane slice is not infnitesimally thin. The ultrasound 533 Ward’s Anaesthetic Equipment beam has a signifcant width in the out-of-plane or eleva- exact one-to-one representation of the target being imaged. This may be 2–3 mm for a 10 Mhz trans- Every imaging modality has artefacts and ultrasound ducer. This is known as slice thickness and tissue that is imaging has them resulting from the fact that pulses of outside the image plane, but still within the elevation plane sound in a beam of fnite width are bouncing around beam width, will also send echoes back to the transducer. It is minimized by the manufacturer putting a weak prove to be useful in helping to identify particular types of cylindrical lens across the front of the transducer probe to targets or anatomical structures. In order to make a correct give some mild focusing in the elevation plane direction. Firstly, this gives some information on the nature of the target; for example, calcifed plaque will have a bright surface with shadowing behind. Secondly, there is a loss of information within the shadow and the probe may have to be repositioned to see what is there. Where Cylindrical lens an artery is viewed in cross-section, the walls parallel to the axis of the beam will not be imaged. The sound is defected by the shallow angle of the fbrous adventitia Elevation plane Slice thickness around the tangent to the beam axis and there will be shadowing behind it. The consequence is that behind the fuid-flled struc- plane beam width is the slice thickness. This effect is known as post cystic enhancement and, in the liver are, therefore, misplaced above the diaphragm together with the dark image of the fuid, is confrmation in the lung space. Another situation where refection arte- that the structure seen in the image is fuid flled, such as fact is seen is when looking down into the supraclavicular a cyst, a blood vessel or other fuid collection. The pulses that have travelled Apart from giving some general reduction in sharpness of twice between refecting layers before going back to the the image, this can give rise to a specifc artefact seen when transducer will arrive later and so will be misplaced in the viewing curved surfaces such as a longitudinal view of an image, appearing as duplicates of the real structure at artery. There may be several of these plane direction, it is still within the beam of the transducer depending on how many times the pulse bounces between and so still sends back echoes. The refection may be between an as a thickening or extension of the vessel wall into the interface and the front surface of the probe, in which case blood-flled vessel lumen, which would normally appear the reverberation artefact will be at twice the distance of black on the image. This will be the case if a hard solid target starts to ring like a bell when it is hit by an ultrasound pulse. The Throughout the image forming process in soft tissue, the effect is seen on the image as a bright streak or comma assumption is made that the speed of sound is constant at 1540 m s−1. This is a useful method to detect foreign bodies in tissue and to spot tissue varies by a small amount between the different where a needle is, from the reverberation comma seen tissue types gives rise to refraction artefacts. This appears to bend at the air–water interface due to the dif- results in a duplicate of one part of the target being mis- ference in the speed of light in air and water. An example is seen tion caused in an ultrasound image is not usually noticed, when imaging the liver with the probe angled cephalad toward the diaphragm. A mirror image of the liver is seen in the air-flled space above the diaphragm as the ultra- sound beam changes direction, refecting back into the liver, whilst the scanner continues to draw a straight image Figure 31. The subclavian artery is duplicated due to refection from the upper surface Figure 31. They are an image of the arterial wall picked up in the elevation plane as shown in B. The easiest way to obtain this longitudinal view is to image the vessel in cross-section with the vessel in the centre of the feld of view. Then rotate the probe into the longitudinal view keeping the vessel at the centre of the image as you do so. Some tissues have a particular orientation of their struc- tural components causing the ultrasound appearance to vary, depending on the orientation of the image. For example, anisotropy is seen in muscle which has a very strongly striated appearance when viewed along the muscle fbres, but a more uniform appearance when viewed across Figure 31. The effect can be to make the target diffcult to see if the probe orientation is not ideal (Fig. In order to produce a bright sharp surface of an anatomi- cal structure in an image, it is necessary to angle the ultra- Compound mode sound probe so that the ultrasound beams insonate the surface of that structure at 90° (Fig. This tinct and slice thickness, refection and shadowing arte- mode sends ultrasound beams into the body at several facts become more apparent. Hence if a blood vessel is angles to the face of the transducer from across the whole 536 Physics and technology of ultrasound Chapter | 31 | A B Figure 31. With slight alteration of the probe angle the nerve (marked in B) becomes less visible. The effect of this is to insonate each Harmonic imaging target from a range of angles so reducing the effect of shadowing by sending beams in behind the obstacle, and Some scanners have a harmonic imaging mode that the showing the curved surface of rounded structures more user can switch on or off (Fig. This mode reduces uniformly as the surface is seen by a beam insonating it the effects of some artefacts, lessening what is often called perpendicularly at more points. Use of compound mode clutter in the image, and gives some improvement in reso- may reduce frame rate and give some blurring of edges due lution. It uses the fact that as an ultrasound pulse travels to misregistration of images from multiple directions. What is happening is that some of the energy of the pulse is going into a higher frequency at double the Ultrasound probe fundamental frequency of the pulse wave. This improves the resolution as the imaging frequency is Colour pixel effectively increased. When using harmonic imaging, the penetration is often poorer and image contrast is reduced. Flow Colour Doppler ultrasound The Doppler effect is very familiar to anyone who has stood at the side of the road and heard a fast police car pass by with its siren going. The Doppler effect is the change in the pitch of the siren heard as the sound waves are squashed together to give a higher frequency as the source comes towards the ‘observer’ and stretched out to Figure 31. In par- ticular it is very useful for detecting blood vessels and to aid identifcation of arteries and veins according to the scale with red-yellow for increasing velocity in one direc- direction and pulsatility of fow within them. The difference between received and transmitted angle may be changed, causing angled ultrasound beams frequencies is known as the Doppler frequency. Over the years, prefxes used to form decimal multiples and submultiples this metric system has been adopted throughout the world (Table App. Multi-lumen referred to by a nominal gauge (G) derived from the catheters and other larger diameter devices (particularly observed fow rate. Level of Personality Organization (Severity of Disturbance) The Continuum of Personality Health The recognition that personality health–disturbance is a dimension or continuum has evolved over decades of clinical observation and research. At the healthy end of the continuum are people who show good functioning in all or most domains. At the severely disturbed end of the continuum are people who respond to dis- tress in rigidly inflexible ways, for example, by relying on a restricted range of costly or maladaptive defenses, or have major and severe deficits in many of the domains described in the Summary of Basic Mental Functioning: M Axis (e. Historical Context of Levels of Personality Organization By the end of the 19th century, psychiatric classification distinguished between two general types of problems: (1) “neurosis,” a term that may refer to either minor or major psychopathology in which the capacity to perceive reality is intact; and (2) “psychosis,” in which there is significant impairment in reality testing. In the ensuing decades, as clinicians slowly appreciated that many people suffer not from isolated symptoms but from issues that pervade their lives more totally, they also began to distinguish between “neurotic symptoms” and “neurotic character,” or what we now call “personality disorder. Slowly, a “borderline” group was identified (Frosch, 1964; Knight, 1953; Main, 1957; Stern, 1938). The concept of a disturbance on the “bor- der” between psychosis and neurosis was subsequently investigated empirically (e. Patients construed as psychologically organized on that border often fared badly in the kinds of treatments that were usually helpful to healthier patients. They would unexpectedly develop intense, problematic, and often rapidly shifting attitudes toward their therapists. Some who did not show psychotic tendencies outside therapy devel- oped intractable “psychotic transferences” (e. A consensus gradually evolved that personality syndromes exist on a continuum of severity, from a comparatively healthy to a severely disturbed level. This continuum has been conventionally, if somewhat arbitrarily, divided into “healthy,” “neurotic,” “borderline,” and “psychotic” levels of personality organization.