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Checking off any one item from the list means that you should strongly consider a profes- sional consultation discount atorlip-10 10 mg without a prescription. If you’re really not sure if you need help buy cheap atorlip-10 10 mg online, see a mental health professional for an assessment 10 mg atorlip-10 with amex. Worksheet 1-10 The Serious Symptom Checklist ❏ I have thoughts about killing myself buy atorlip-10 10 mg online. If you checked one or more of the statements above and you’re beginning to think that per- haps you need help, where should you go? Many people start with their family physicians, which is a pretty good idea because your doctor can also determine if your problems have a physical cause. If physical problems have been ruled out or treated and you still need help, you can: Part I: Analyzing Angst and Preparing a Plan 18 Check with your state’s psychology, counseling, social work, or psychiatric association. Contact your local university department of psychology, social work, counseling, or psychiatry for a referral. Either before or during your first session, talk to the mental health professional and ask if you’ll receive a scientifically validated treatment for anxiety or depression. Unfortunately, some practitioners lack necessary training in therapies that have shown effectiveness in sci- entific studies. Chapter 2 Discovering the Beginnings In This Chapter Burrowing through biology Studying your history Reviewing what’s happening now Finding fault (or not) f you’re reading this book, you probably feel a little anxious or depressed. It’s valuable to understand the origins of your feelings, whether its biology and genetics, personal history, or stress. This chapter helps you gain insight into the source of your problem and connect the dots, because knowing the origins of your emotions allows you to discard the baggage of guilt and self-blame. In this chapter, we review the major causes of depression and anxiety: biology, personal his- tory, and stress. Many of our clients come to us believing that they’re to blame for having succumbed to emotional distress. When they discover the factors that contributed to the origins of their problems, they usually feel less guilty, and getting rid of that guilt frees up energy that can be used for making important changes. If you have access to family members, ask if they’d be willing to talk with you about your family’s history. Ask them if any relatives, from either side of the family, suffered from any symptoms of anxiety or depression. There’s no exact number of relatives required for determining if genetics are responsible for your symptoms. However, the more family members with similar problems, the more likely you’ve inherited a tendency for depression or anxiety. Part I: Analyzing Angst and Preparing a Plan 20 Members of my family with anxiety or depression (brothers, sisters, cousins, parents, uncles, aunts, and grandparents): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ In addition to genetics, depression and anxiety can have biological underpinnings in the drugs you take (legal or illegal) or as the result of physical illness. Drugs — whether over- the-counter, prescription, or illegal — have many side effects. Sometimes solving your problem is as simple as checking your medicine cabinet for possible culprits. Check with your pharmacist or primary care physician to see if your medication may be causing part of your problem. In addition, alcohol is widely known to contribute to depression or anxiety when it’s abused. Some people find that even moderate amounts of alcohol exacerbate their problems with mood. Alcohol also interacts with a wide variety of prescribed and over-the-counter drugs to produce harmful and even deadly results. Finally, illegal drugs such as marijuana, cocaine, heroin, methamphetamine, ecstasy, and so on are taken to alter moods. In the short run, they accomplish that goal; but in the long run, they almost inevitably worsen mood problems. Not only can the ill- ness itself cause mood problems, but worry and grief about illness can contribute to your distress. If you’ve been diagnosed with a medical condition, check with your doctor to see if your depression or anxiety is related to that condition.

Microscopic and Biochemical Analyses Such analyses of the penile swabs may be undertaken to identify cellular material generic 10mg atorlip-10 fast delivery, blood atorlip-10 10 mg low price, or amylase cheap 10 mg atorlip-10 with visa. When the complaint is of anal intercourse purchase 10mg atorlip-10 amex, swabs that are discolored by fecal material can be analyzed for urobilinogen and examined microscopically for vegetable matter. Blood and feces have been recovered from penile swabs taken 15 and 18 hours, respectively, after the incident (for saliva, see Subheading 7. Medical Evidence When obtaining the relevant forensic samples, the forensic practitioner should inspect the male genitalia with particular reference to the following points: 1. Pubic hair should be described in terms of its coarseness, distribution (Tanner stages 1–5), and color. A note should be made if the pubic hair appears to have been plucked (including bleeding hair follicles), shaved, cut, or dyed. Acquired abnormalities, such as circumcision, Peyronie’s disease, balanitis xerotica obliterans, vasectomy scars, phimosis, tattoos, and piercing. Foreign bodies may be worn around the base of the penis, sometimes also encir- cling the scrotum, in an attempt to increase and sustain penile tumescence. Such devices may result in local and distal genital trauma (penile tourniquet syndrome) (157). In several case reports, children have had human hairs wrapped around the penis; these hairs may be virtually invisible because of edema or epithelialization (158). Kerry and Chapman (159) have described the deliberate application of such a ligature by parents who were attempting to prevent enuresis. After consensual sexual intercourse, lacerations of the foreskin and frenulum, meatitis, traumatic urethritis, penile edema, traumatic lymphangitis, paraphimosis, and penile “fractures” have all been described (160– 163). Accidental trauma is more common when there is a pre-existing abnormal- ity, such as phimosis (160). Skin injury may be incurred if the genitals are deliberately bitten during fellatio (160). Although the precise incidence of male genital trauma after sexual activity is unknown, anecdotal accounts suggest that it is rare to find any genital injuries when examining suspects of serious sexual assaults (164). In children the genitalia may be accidentally or deliberately injured, and the latter may be associated with sexual abuse (165). Bruises, abrasions, lac- erations, swelling, and burns of the genitalia of prepubescent males have all been described (165,166). Definitions Buggery is a lay term used to refer to penile penetration of the anus (anal intercourse) of a man, a woman, or an animal (also known as bestiality). Consensual Although anal intercourse among heterosexuals is the least common com- ponent of the sexual repertoire, it has been experienced on at least one occa- sion by 13–25% of heterosexual females surveyed (64,80,167), and it was described as a regular means of sexual gratification for 8% of women attend- ing one gynecologist (80). Among 508 men who reported having had a same- gender sexual experience at some stage in their lives, 33. Inter- estingly, in contrast to a common perception, more men had experienced both practices than had been in exclusively receptive or insertive roles (168). Nonconsensual Anal intercourse was reported by 5–16% of females who described hav- ing been sexually assaulted (6,169). Although it may be the only sexual act performed, it is more frequently combined with vaginal and oral penetration (6,169). Fewer data are available regarding sexual assaults on males, although Hillman et al. Legal Implications Under English common law, the term buggery is defined as anal inter- course by a man with another man or a woman and anal or vaginal inter- course by a man or a woman with an animal (bestiality). Although the 1967 Sexual Offences Act provided that it was not an offense for two consenting men who had attained the age of 21 to commit buggery in private, it remained an offense for a man to commit buggery with a woman, even if both parties consented, until 1994. The Criminal Justice and Public Order Act 1994 expanded the definition of rape, which had previously related to only vaginal intercourse, to include nonconsensual penile penetration of the anus independent of the gender of the recipient. The Sexual Offences (Amendment) Act 2000 reduced the minimum age at which a person, whether male or female, may lawfully consent to bug- gery to 16 years. A recent change in English law has defined nonconsensual penetration of the anus by an object or a body part (excluding the penis) as “assault by penetration,” this new offense has the same maximum sentence as rape. In some other jurisdictions, such as Australia, such acts are included in the legal definition of rape (172). Anatomy and Physiology An understanding of the normal anatomy and physiology of the perianal area and anal canal is important for the reliable description and interpretation of the medical findings after allegations of anal penetrative acts.

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This record can help the healthcare provider and the patient plan effective pain management purchase 10mg atorlip-10 mastercard. The pain management plan contains both pharmacological and nonpharma- cological strategies for managing the patient’s pain cheap atorlip-10 10mg on line. These include massage generic atorlip-10 10 mg on-line, imagery cheap 10mg atorlip-10 with visa, music, distraction, humor, acupuncture, chiropractic interventions, hypnosis, herbal therapies, ther- apeutic touch, and transcutaneous electronerve stimulation. Pharmacologic Management of Pain Pharmacologic management of pain involves administering pain medication to relieve the patient’s pain. Non-narcotic analgesics are used to treat headaches, menstrual pain (dysmenor- rheal), pain from inflammation, minor abrasions, muscular aches and pain, and mild-to-moderate arthritis. Narcotic analgesics are also used to suppress coughing by acting on the respiratory and cough cen- ters in the medulla of the brain stem. All relieve pain and all, except meperidine (Demerol), have an antitussive (cough suppression) and antidiar- rheal effect. Although the exact mechanism of action is unknown, these agents have both agonist and antagonist effects on the opioid receptors. Commonly used narcotic agonist-antagonists are Pentazocine (Talwin), Butorphanol tartrate (Stadol), duprenorphine (Buprenex), and nalbuphine hydrochloride (Nubain). They have a higher affinity to the opiate receptor site than the narcotic analgesic and block the narcotic analgesic from binding to the opiate receptor site. Naloxone (Narcan) is a narcotic antagonist and can be used to determine if an unconscious patient has used an opioid narcotic drug. If the patient wakes up after Narcan is administered intravenously, the patient is likely to have ingested or injected an opioid narcotic. Summary Pain is sensed when a nerve ending is stimulated sending an impulse along the neural pathway to the brain that interprets the impulse as pain. Pain is assessed in a patient by asking the patient to describe the intensity of the pain on a pain scale—the higher the value, the more severe the pain. Besides intensity, pain is assessed according to onset, duration, frequency, what started the pain (precipi- tating cause), and what relieves the pain. There are six classifications of pain: acute pain, chronic pain, visceral pain, somatic pain, neuropathic pain, and psychogenic pain. Nonpharmacological pain treatment includes massage, imagery, music, dis- traction, humor, acupuncture, chiropractic interventions, hypnosis, herbal thera- pies, therapeutic touch, and transcutaneous electronerve stimulation. Narcotic analgesics are opioid narcotics that can induce respiratory depres- sion. The effects of a narcotic analgesic can be reversed by administering a nar- cotic antagonist. Many patients and healthcare providers are concerned that a patient will become addicted to narcotic analgesics or develop a tolerance for these drugs. In the next chapter, we’ll take a look at medications that are used to control the immune system. Physical sensation of pain (a) occurs when nerve endings are stimulated causing it to send an impulse along the nerve pathways to the brain. The presence of severe discomfort or an uncomfortable sensation that has a sudden onset and subsides with treatment is (a) neuropathic pain. The color scale uses colors ranging from blue to red where blue is free- dom from pain and red is the most severe pain. Pain occurring from skeletal muscles, fascia, ligaments, vessels, and joints is called (a) neuropathic pain. The immune system also treats its own abnormal cells, such as cancer cells, as foreign and attacks it with the same energy as it attacks microorganisms. The patient encounters more episodes of infection that can ultimately lead to death. A Brief Look at Immunity The immune system is the body’s way of combating the invasion of micro- scopic organisms such as bacteria, viruses, molds, spores, pollens, protozoa, 315 Copyright © 2006 by The McGraw-Hill Companies, Inc. The immune system pre- vents an invasion from attacking internal organs and, if that fails, the immune system neutralizes, destroys, and eliminates any non-self proteins and cells, including microorganisms.

Research of this kind continues to expand the possibilities of contributions that can be made in investigations involving dental remains generic 10mg atorlip-10 with amex. However buy 10 mg atorlip-10, other 3D imaging advances are worthy of mention because of their potential appli- cation to forensic odontology purchase 10mg atorlip-10 otc. Improvements in computer technologies have Forensic dental identifcation 181 led to the development of hardware and sofware that can create 3D models following the scanning of objects buy atorlip-10 10 mg otc. A scanner developed by 3M, the Lava™ Chairside Oral Scanner, and other intraoral image capture systems of this type are used to create accurate 3D models to be used for the indirect fabrication of fxed dental prosthetics. It is not difcult to envision that these same components or their derivatives could be utilized to make 3D scans of postmortem cases to compare to archived 3D antemortem scans, leading to positive dental iden- tifcations. Tese and other advances in dental and forensic technologies coupled with optimal clinical practices that stress meticulous record keeping, includ- ing recording the specifc dental materials used in patient care, will become important tools for forensic dentists, facilitating identifcations and the return of loved ones to their families. As obvious as this may seem, if, in a post- mortem case, a tooth is unrestored, all antemortem records show- ing a restoration in that same tooth can be eliminated. A restoration may have been placed afer the most recent antemortem record, but not the opposite—teeth do not heal. If an antemortem radiograph demonstrates that a tooth is missing and that tooth is present in a postmortem radiograph, the forensic odontologist can exclude that postmortem record. As in all methods of identifcation, postmortem informa- tion must be compared to a known individual’s antemortem informa- tion. Until the body of a specifc individual is found and the data compared, no identifcation is possible. Flips occur when dentists or assistants erroneously 182 Forensic dentistry record treatments to the contralateral tooth, the tooth on the other side of the arch, i. Slides occur, most commonly, when teeth have been lost and other teeth drif into their spaces. With the increased use of digital radiography, the incidence of lost radiographs should decrease. Digital dental sofware programs inter- nally record the date an image is entered into the fle. Dentists are encouraged to keep complete and accurate dental records to facilitate dental identi- fcation and to protect the dentist in case of legal actions. When examining antemortem radiographs forensic dentists should remember that additional treatment may have been com- pleted on that patient in the interim period. Ignoring that possibility may lead to recording points of discrepancy that are, in fact, explain- able. Every practical attempt should be made to procure the latest available treatment record. Advances in dental material science have changed dental identifcation methodology. Te technological advances in dental resin materials coupled with the increased demand for esthetic restorations have further complicated some forensic comparisons. Te use of amalgam flling material is declining and is being replaced with the use of increasingly varied composite resin materials. Dental techniques, including microdentistry and the use of fowable resins, have made the postmortem examination process more complex. Forensic dentists must inspect restorations during postmortem examinations with a great deal more scrutiny than in the past, when “tooth colored” restorations were usually only seen in anterior teeth. Te restored surfaces of a tooth may appear more extensive in the postmortem exam than is recorded in an antemortem record for a specifc tooth. Te forensic dentist that assumes this to be a discrepancy may make the error of forgetting that additional dental treatment to that tooth may have occurred afer the latest antemortem record entry. Multisurface amalgam restorations may have been replaced with full crowns by a diferent dentist. Tese occurrences can Forensic dental identifcation 183 be labeled as “explainable discrepancies” or “logical progressions” and are not necessarily reasons to exclude a record in the compari- son process if other overwhelming information indicates that the two records are records of the same individual. When examining the antemortem radiographs, care must be taken to ensure that the x-rays are oriented correctly. If the antemortem x-rays are duplicates and not labeled as L or R and the flm dimple location is indeterminable, then the forensic dentist must request additional information from the submitting dentist, most ofen the original flms. Original flms should always be acquired and examined since duplicate flms are very ofen incorrectly oriented (see Chapter 10).

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