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She briefly lost consciousness but quickly woke back up and tried to help her severely wounded fellow soldiers, several of whom died of their injuries. I think you experienced a probable mild traumatic brain injury in the blast. I also think you have ptsd. The ptsd can cause a lot of problems, and can make your migraines worse. The good news is ptsd is treatable. I want you to start a uoxetine and follow up with a psychiatrist.

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•• for insomnia select medications whose duration of action matches the timing of the generic viagra sildenafil difficulty sleeping (eg, difficulty initiating or maintaining sleep). Follow-up evaluation. •• evaluate improvement in the specific sleep complaint (eg, how has therapy affected sleep latency or sleep maintenance?. ). •• monitor daytime sleepiness, sleep diaries, and diaries of sleep events (plms, hallucinations, snoring, apneas, etc) and monitor cataplexy and other daytime symptoms to determine if therapy is effective. •• make appropriate changes to therapy to address inadequately controlled symptoms and reported adverse effects. Outcome evaluation evaluate whether the treatment plan restored normal sleep patterns, reduced daytime sequelae, and improved quality of life without causing adverse effects. Schedule patients for follow-up within 3 weeks for insomnia and within 3 months for other sleep disorders. Perform a detailed clinical history to determine the patient’s perception of treatment progress and symptoms along with medication effectiveness and side effects. Instruct patients to keep sleep diaries (number of hours, number of awakenings, and worsening or improved sleep) and daytime symptoms, along with documentation of episodes such as cataplexy or rbd. Increase medication to effective doses, and if necessary, start additional therapy to control symptoms. Patients with sleep disorders should experience relief of symptoms the first night of drug therapy but may not receive maximal benefit (effect on daytime symptoms) for a few weeks. Perform a detailed history of prescription, nonprescription, and complementary or alternative medications and review the patient’s sleep diary, daytime symptoms, and nonpharmacologic therapies on a regular basis. Abbreviations introduced in this chapter autopap bipap bmi bzdra cns cpap crd da eds eeg ess fda gaba mslt mwt npsg nrem osa plms rbd rdi rem rls snri ssri tca auto-titrating continuous positive airway pressure bilevel positive airway pressure body mass index benzodiazepine receptor agonist central nervous system continuous positive airway pressure circadian rhythm disorder dopamine agonist excessive daytime sleepiness electroencephalogram epworth sleepiness scale food and drug administration γ-aminobutyric acid multiple sleep latency test maintenance of wakefulness test nocturnal polysomnography non–rapid eye movement obstructive sleep apnea periodic limb movements of sleep rem-sleep behavior disorder respiratory disturbance index rapid eye movement restless legs syndrome serotonin/norepinephrine reuptake inhibitor selective serotonin reuptake inhibitor tricyclic antidepressant references block dopaminergic transmission may worsen rls symptoms. Alcohol and cns depressants, including opiates, sedatives, and muscle relaxants, can worsen osa, even in small doses, by reducing respiratory drive and relaxing the upper airway muscles responsible for maintaining patency. Cns depressants should be avoided, and if they are necessary, they should not be administered before sleep. Drug therapy for sleep disorders should be patient specific, and careful consideration should be given to coexisting diseases, concomitant medications, and potential drug–drug and drug–disease interactions to optimize patient care and treatment. 1. Malow b. Approach to the patient with disordered sleep. In. Kryger m, roth t, dement w, eds. Principles and practice of sleep medicine.

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B. Pn support. If growth targets cannot be achieved using enteral feeds, continued use of supplemental pn may be indicated depending on the patient's overall status and liver function. Enteral feeding should be continued at the highest rate and nutritional density tolerated, and supplemental pn should be given to achieve the nutritional goals and growth outcomes as previously outlined. C. Bpd. Preterm infants who have bpd have increased caloric requirements due to their increased metabolic expenditure, and at the same time have a lower tolerance for excess fluid intake (see chap. 34). I. Fluid restriction. Total fluid intake is typically restricted from the usual150 mukglday to 140 mukglday. In cases of severe bpd, further restriction to 130 mukg/day may be required. Careful monitoring is required when fluid restrictions are implemented to ensure adequate caloric and micronutrient intake. Growth parameters must also be monitored so that continued growth is not compromised. Fluid electrolytes nutrition, gastrointestinal, and renal issues i 2 61 2. Caloric density. Infants with bpd will commonly require up to 30 kcal/oz feeds in order to achieve the desired growth targets. Vi. Nutritional considerations in discharge planning. Recent data describing postnatal growth in the united states suggest that a significant number of vlbw and elbw infants continue to have catch-up growth requirements at the time of discharge from the hospital. However, there is a paucity of data regarding what to feed the preterm infant after discharge. A human milk. The use of human milk and efforts to transition to full breastfeeding in former preterm infants who continue to require enhanced caloric density fuedings, poses a unique challenge. Individualized care plans are indicated in order to support the transition to full breastfeeding while continuing to allow for optimal rates of growth. Usually, this is accomplished by a combination of a specified number ofnursing sessions per day, supplemented by feedings of calorically enhanced breast milk or nursing on demand supplemented by several feeds per day of nutrient-enriched postdischarge formula. Growth rate data obtained in the hospital are typically forwarded to infant follow-up clinics and the private pediatrician for vlbw and elbw infants. B. Formula choi~ 1. Nutrient-enriched postdischarge formulas. The aap suggests a recent metaanalysis of randomized controlled trials concluded that these formulas have limited benefits at best for growth and development up to 18 months after term compared with standard infant formulas. In some of the trials, infants on standard formula increased their volume of intake, therefore, mostly compensating for any additional nutrients from the postdischarge formulas. The espghan has suggested that preterm infants who demonstrate subnormal weight for age at discharge should be fed with fortified human milk or special formula fortified with high contents of protein, minerals, and trace elements, as well as lcpufas until at least 40 weeks' pma, but possibly for another 3 months thereafter. In practice, preterm infants are considered to be appropriate candidates for the use of these formulas, either as an additive to human milk or as a sole formula choice, once they are >2,000 g and 35 weeks' corrected gestational age.

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“ if patient has plan, evaluate whether patient has the means to carry out it. Eg, if a patient who has thought about overdosing on pills has stockpiled medication past behavior “have you ever tried to kill yourself before?. “ if yes. Nd out how many attempts, when, how, what precipitated, whether impulsive or premeditated, whether patient intended to die “have you ever done things on purpose to hurt yourself when you didn’t want to die, like cutting, hitting, or burning yourself?. ” protective/triggering factors “is there anything that would keep you from committing suicide?. ” examples. Religious beliefs, not wanting to harm family, etc. “is there anything you think might push you over the edge and make you try to hurt yourself?. ” examples. Abandonment by signi cant others, nancial setbacks, receiving bad news, etc. ▲ figure 49-1 evaluation o suicidality. Data rom practice guideline or the assessment and treatment o patients with suicidal behaviors. Am j psychiatry. 2003;160(11 suppl):1-60. How should a neurologist respond when there are concerns for suicidality or homicidality?.