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Child abuse must be reported to appropriate authorities if suspected in all states 150mg venlafaxine amex anxiety symptoms throwing up. Simi­ larly buy venlafaxine 150mg without a prescription anxiety 4 year old boy, certain infctions 37.5 mg venlafaxine fast delivery anxiety fear, such as active tuberculosis cheap venlafaxine 150 mg with amex anxiety icd 9, must be reported to public health ofcials. Active suicidal ideation, especially if there is a plan and access to agents necessary to implement the plan, may lead the physician to intervene to prevent the action. Emancipation implies that the patient is able to make decisions regarding health-related issues but does not give the patient the right to vote, consume alcohol, or use tobacco products if the patient is not of legal age. Only 12 states currently allow a minor to have an abortion without the consent of or notifcation to parents. However, the clinician should attempt to administer confidential health care to minors seeking care fr sensitive medical issues when it is saf and appropriate to do so. Confdential health care fr adolescents: position paper of the Society fr Adolescent Medicine. Adolescent patient confidentiality: whom are we kidding [editorial Jr]Adolesc Health. She reports feling "dizzy" on and off fr the past year; the dizziness is associated with weakness that has been worsening fr the past month. Review of systems is signif­ icant fr knee pain, fr which she frequently takes aspirin or ibuprofn; otherwise the review of systems is negative. She has no significant medical history and has not been to a doctor in several years. She had a normal well-woman examination and screening colonoscopy about 5 years ago. On examination, her blood pressure is 150/85 mm Hg; her pulse is 98 beats/min; her respiratory rate is 20 breaths/min; her temperature is 98. The remainder of the examination, including respiratory, cardiovascular, and nervous systems, was normal. Considerations A 65-year-old woman who has developed worsening dyspnea and palpitations over 1-week period of time needs to be evaluated fr cardiac and respiratory problems despite the gradual onset of symptoms. Specifcally, in a postmenopausal woman, signs and symptoms of angina or acute myocardial infrction may not always have a typical presentation. That the patient has been feeling weak and has conjunctival pallor warrants testing fr anemia. Assuming that the initial workup fr cardiac and pulmonary causes is negative and that the hemoglobin and hematocrit levels are low, a thorough evaluation fr the cause of the anemia is necessary. If this patient was fom a developing country, the possibility of intestinal parasites would need to be considered. Weight loss, lymphadenopathy, and coagulopathy may warrant evaluation fr nongastroin­ testinal malignancies, such as leukemias or lymphomas. These diferences are reportedly a result of biologic, not socioeconomic, diferences. Most studies show the rate of anemia to be higher in men than women and there is increasing evidence fr anemia as an independent risk fctor fr increased morbidity and mortality and decreased qual­ ity of life (Level B recommendation). Cinical Presentation Fatigue, weakness, and dyspnea are symptoms that are commonly reported by elderly persons with anemia. For example, the reduced oxygen-carrying capacity of the blood as a consequence of anemia may exacerbate dyspnea associated with congestive heart filure. Conjunc­ tvl pallor is recommended as a reliable sig of anemia in the elderly and commonly noted i patents with hemogobin less than 9 g/dL. Glossitis, decreased vibratory and positional senses, ataia, paresthesia, confsion, dementia, and pearly gray hair at an early age are signs sug­ gestive of vitamin B12-defciency anemia. Profund iron defciency may produce koilony­ chias (spoon nails), glossitis, or dysphagia. Jaundice can be a clue that hemolysis is a contributing fctor to the anemia, whereas splenomegaly can indicate that a thalas­ semia or neoplasm may be present. Further laboratory studies would be indicated based on the results of the initial tests and the presence of symptoms or signs suggestive of other diseases. Other causes of microcytic anemia include thalassemias and anemia of chronic disease. In the elderly, iron defciency is fequently caused by chronic gastrointestinal blood loss, poor nutritional intake, or a bleeding disorder. The presence of macrocytic anemia, with or without the symptoms previously mentioned, should lead to frther testing to determine B12 and flate levels. Folate defciency anemia is usually seen in alcoholics, whereas B12-defciency anemia mostly occurs in people with pernicious anemia, a history of gastrectomy, and diseases associated with malabsorption (eg, bacterial infection, Crohn disease, celiac disease). Under normal conditions, the body stores 50% of its B12 (2-5 mg total in adults) in the liver fr 3 to 5 years. B12 defciency can be distinguished clinically fom flic acid defciency by the presence of neurologic symptoms. In the elderly, anemia of chronic infammation (frmerly known as anemia of chronic disease) is the most common cause of a normocytic anemia. Anemia of chronic infammation is anemia that is secondary to some other underlying condi­ tion that leads to increased inflammation and bone marrow suppression. Along with causing a normocytic anemia, anemia of chronic infammation can also present as a microcytic anemia. This type of anemia can easily be confsed with iron-defciency anemia because of its similar initial laboratory picture. A lack of improvement in symptoms and hemoglobin level with iron supplementa­ tion are important clues indicating that the cause is chronic disease and not iron depletion, regardless of the laboratory picture. Another cause of normocytic ane­ mia is renal insufciency due to decreased erythropoietin production. Treatment The treatment of anemia is determined based on the tye and cause of the anemia. Any cause of anemia that creates a hemodynamic instability can be treated with a red blood cell transfsion. A hemoglobin less than 7 g/dL is a commonly used threshold fr transfsion; however, transfsion may be indicated at higher levels if the patient is symptomatic or has a comorbid condition such as coronary artery disease. Iron-defciency anemia is treated frst by identifcation and correction of any source of blood loss. Oral iron is given as frrous sulfte 325 mg (contains 65 mg of elemental iron) three times a day. In uncomplicated anemia, it is considered frst-line therapy given its low cost and easy accessibility. Adherence to oral iron may be poor due to gastrointestinal side efects (dark stools, nausea, vomiting, and constipation) and the required 6 to 8 weeks of treatment needed to correct the anemia.

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The most common adverse effects are breast discomfort cheap 150 mg venlafaxine overnight delivery anxiety coping skills, headache discount venlafaxine 150 mg on line anxiety vs fear, local irritation generic venlafaxine 75 mg fast delivery anxiety zoloft, nausea buy 37.5 mg venlafaxine amex anxiety meds, and menstrual cramps. Vaginal Contraceptive Ring NuvaRing is a hormonal contraceptive device designed for vaginal insertion. The ring is made of transparent, flexible material and looks like a very skinny doughnut, with an overall diameter of 2. Each day, the ring releases 15 mcg of ethinyl estradiol and 120 mcg of etonogestrel. After release, the hormones penetrate the vaginal mucosa, undergo absorption into the blood, and then distribute throughout the body. One ring is inserted once each month, left in place for 3 weeks, and then removed; a new ring is inserted 1 week later. If a ring is expelled before 3 weeks have passed, it can be washed off in warm water (not hot water) and reinserted. If more than 3 hours elapse between ring expulsion and reinsertion, contraceptive effects may be diminished, and hence backup contraception should be used for 7 days. Initiating ring use is done as follows: • For women not currently using contraception, ring use should start anytime during days 1 through 5 of the menstrual cycle, even if bleeding is ongoing; backup contraception should be used during the first 7 days. The most common adverse effects are vaginitis, headaches, upper respiratory infection, leukorrhea, sinusitis, weight gain, and nausea. Common reasons for discontinuing the ring include foreign body sensations, coital problems, ring expulsion, vaginal symptoms, headache, and emotional lability. Long-Acting Contraceptives Subdermal Etonogestrel Implants A subdermal system [Nexplanon] for delivery of etonogestrel is available for long-term, reversible contraception. Description Nexplanon consists of a single 4-cm rod that contains 68 mg of etonogestrel, a synthetic progestin. The rod is implanted subdermally in the groove between the biceps and triceps in the nondominant arm. Etonogestrel then diffuses slowly and continuously, providing blood levels sufficient for contraception for 3 years, after which the rod is removed. Mechanism of Action Etonogestrel suppresses ovulation and thickens cervical mucus. In addition, it causes the endometrium to become involuted and hence hostile to implantation. Pharmacokinetics Daily release of etonogestrel is 60 to 70 mcg initially and gradually declines to 25 to 30 mcg over 3 years. Adverse Effect: Irregular Bleeding In women using Nexplanon, bleeding episodes are irregular and unpredictable. In clinical trials, amenorrhea occurred in 22% of women; infrequent bleeding (less than three bleeding or spotting episodes in 90 days) occurred in 34% of women; frequent bleeding (more than five bleeding or spotting episodes in 90 days) occurred in 7% of women, and prolonged bleeding (more than 14 days of bleeding in 90 days) occurred in 18% of women. The general pattern of irregular and unpredictable bleeding does not change while using Nexplanon. Use During Breastfeeding Nexplanon is safe to use during breastfeeding after the 21st postpartum day. In a controlled clinical trial, there were no significant effects on the physical or psychomotor development of infants. Also, Nexplanon had no effect on the production or quality of milk, even when implanted just a few days postpartum. The drug thereby (1) inhibits follicular maturation and ovulation, (2) thickens the cervical mucus, and (3) causes thinning of the endometrium, making implantation unlikely. When injections are discontinued, return of fertility is delayed (by an average of 9 months). To ensure that the recipient is not pregnant, the first dose should be given either (1) during the first 5 days of a normal menstrual period, (2) within the first 5 days postpartum (if not breastfeeding), or (3) at the sixth week postpartum (if exclusively breastfeeding). Most adverse effects are like those seen with other progestin-only contraceptives. Menstrual disturbances are common; menstruation may be irregular at first and then, after 6 to 12 months, may cease entirely. Women may also experience abdominal bloating, headache, depression, and decreased libido. ParaGard can remain in place for 10 years, Mirena for 5 years, and Liletta and Skyla for 3 years. These devices prevent conception by producing a harmless local inflammatory response that is spermicidal. Mirena, whose active ingredient is levonorgestrel, also causes endometrial involution and thickening of the cervical mucus. Spermicides Spermicides are chemical surfactants that kill sperm by destroying their cell membrane. These drugs are available in the form of a foam, gel, jelly, suppository, vaginal film, and contraceptive sponge. The spermicide must be applied before intercourse, but no more than 1 hour in advance (when used alone). Containers for foam preparations must be shaken thoroughly before each use to ensure dispersal of the spermicide. Suppositories should be inserted at least 10 to 15 minutes before intercourse to allow time for dissolution. The contraceptive sponge [Today Sponge] is a soft, porous, polyurethane disk impregnated with 1000 mg of nonoxynol 9. When inserted to cover the cervix, it protects against conception by (1) releasing spermicide, (2) absorbing seminal fluid, and (3) blocking penetration of sperm. Unlike other spermicide products, which must be reapplied before each act of intercourse, a single sponge is effective for 24 hours, regardless of how often coitus takes place. The rates of unintended pregnancy with the sponge are high: 16% among typical nulliparous users, and 32% among parous users. In the United States nearly 50% of women aged 15 to 44 years report having had at least one unintended pregnancy. Progestin-Only Emergency Contraception Pills Three progestin-only products are available: Plan B One-Step, Next Choice One Dose, and Next Choice. These products are packaged and marketed specifically for emergency contraception. Plan B One-Step and Next Choice One Dose Plan B One-Step and Next Choice One Dose consist of a single, high-dose (1. The package insert calls for taking the tablet within 72 hours of unprotected intercourse. Plan B One-Step reduces the odds of pregnancy by 89% and Next Choice One Dose prevented 84% of expected pregnancies, which is better than it may seem.

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