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The risk of this disorder developing is increased if physical exhaustion or organic factors medicine 2410 discount 25 mg meclizine free shipping. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions medicine numbers buy meclizine 25mg line, as evidenced by the fact that not all people exposed to symptoms hiatal hernia buy meclizine overnight delivery exceptional stress develop the disorder symptoms uterine fibroids purchase 25 mg meclizine free shipping. The symptoms show great variation but typically they include an initial state of "daze", with some constriction of the field of consciousness and narrowing of attention, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation (to the extent of a dissociative stupor see F44. Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. Diagnostic guidelines There must be an immediate and clear temporal connection between the impact of an exceptional stressor and the onset of symptoms; onset is usually within a few minutes, if not immediate. In addition, the symptoms: 119 (a)show a mixed and usually changing picture; in addition to the initial state of "daze", depression, anxiety, anger, despair, overactivity, and withdrawal may all be seen, but no one type of symptom predominates for long; (b)resolve rapidly (within a few hours at the most) in those cases where removal from the stressful environment is possible; in cases where the stress continues or cannot by its nature be reversed, the symptoms usually begin to diminish after 24-48 hours and are usually minimal after about 3 days. This diagnosis should not be used to cover sudden exacerbations of symptoms in individuals already showing symptoms that fulfil the criteria of any other psychiatric disorder, except for those in F60. However, a history of previous psychiatric disorder does not invalidate the use of this diagnosis. Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories ("flashbacks") or dreams, occurring against the persisting background of a sense of "numbness" and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there may be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden recollection and/or re-enactment of the trauma or of the original reaction to it. Anxiety and depression are commonly associated with the above symptoms and signs, and suicidal ideation is not infrequent. The onset follows the trauma with a latency period which may range from a few weeks to months (but rarely exceeds 6 months). In a small proportion of patients the condition may show a chronic course over many years and a transition to an enduring personality change (see F62. Diagnostic guidelines this disorder should not generally be diagnosed unless there is evidence that it arose within 6 months of a traumatic event of exceptional severity. A "probable" diagnosis might still be possible if the delay between the event and the onset was longer than 6 months, provided that the clinical manifestations are typical and no alternative identification of the disorder. In addition to evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the event in memories, daytime imagery, or dreams. Conspicuous emotional detachment, numbing of feeling, and avoidance of stimuli that might arouse recollection of the trauma are 120 often present but are not essential for the diagnosis. The autonomic disturbances, mood disorder, and behavioural abnormalities all contribute to the diagnosis but are not of prime importance. The stressor may involve only the individual or also his or her group or community. Individual predisposition or vulnerability plays a greater role in the risk of occurrence and the shaping of the manifestations of adjustment disorders than it does in the other conditions in F43. The manifestations vary, and include depressed mood, anxiety, worry (or a mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, and some degree of disability in the performance of daily routine. The individual may feel liable to dramatic behaviour or outbursts of violence, but these rarely occur. None of the symptoms is of sufficient severity or prominence in its own right to justify a more specific diagnosis. In children, regressive phenomena such as return to bed-wetting, babyish speech, or thumb-sucking are frequently part of the symptom pattern. The onset is usually within 1 month of the occurrence of the stressful event or life change, and the duration of symptoms does not usually exceed 6 months, except in the case of prolonged depressive reaction (F43. Grief reactions of any duration, considered to be abnormal because of their form or content, should be coded as F43. Diagnostic guidelines Diagnosis depends on a careful evaluation of the relationship between: (a)form, content, and severity of symptoms; (b)previous history and personality; and (c)stressful event, situation, or life crisis. The presence of this third factor should be clearly established and there should be strong, though perhaps presumptive, evidence that the disorder would not have arisen without it. If the stressor is relatively minor, or if a temporal connection (less than 3 months) cannot be 121 demonstrated, the disorder should be classified elsewhere, according to its presenting features. Includes: culture shock grief reaction hospitalism in children Excludes: separation anxiety disorder of childhood (F93. Symptoms of anxiety and depression may fulfil the criteria for mixed anxiety and depressive disorder (F41. This category should also be used for reactions in children in which regressive behaviour such as bed-wetting or thumb-sucking are also present. There is normally a considerable degree of conscious control over the memories and sensations that can be selected for immediate attention, and the movements that are to be carried out. In the dissociative disorders it is presumed that this ability to exercise a conscious and selective control is impaired, to a degree that can vary from day to day or even from hour to hour. It is usually very difficult to assess the extent to which some of the loss of functions might be under voluntary control. These disorders have previously been classified as various types of "conversion hysteria", but it now seems best to avoid the term "hysteria" as far as possible, in view of its many and varied 122 meanings. Dissociative disorders as described here are presumed to be "psychogenic" in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The term "conversion" is widely applied to some of these disorders, and implies that the unpleasant affect, engendered by the problems and conflicts that the individual cannot solve, is somehow transformed into the symptoms. The onset and termination of dissociative states are often reported as being sudden, but they are rarely observed except during contrived interactions or procedures such as hypnosis or abreaction. Change in or disappearance of a dissociative state may be limited to the duration of such procedures. All types of dissociative state tend to remit after a few weeks or months, particularly if their onset was associated with a traumatic life event. More chronic states, particularly paralyses and anaesthesias, may develop (sometimes more slowly) if they are associated with insoluble problems or interpersonal difficulties. Dissociative states that have endured for more than 1-2 years before coming to psychiatric attention are often resistant to therapy. Individuals with dissociative disorders often show a striking denial of problems or difficulties that may be obvious to others. Any problems that they themselves recognize may be attributed by patients to the dissociative symptoms. Depersonalization and derealization are not included here, since in these syndromes only limited aspects of personal identity are usually affected, and there is no associated loss of performance in terms of sensations, memories, or movements. Diagnostic guidelines For a definite diagnosis the following should be present: (a)the clinical features as specified for the individual disorders in F44. Convincing evidence of psychological causation may be difficult to find, even though strongly suspected. In the presence of known disorders of the central or peripheral nervous system, the diagnosis of dissociative disorder should be made with great caution. In the absence of evidence for psychological causation, the diagnosis should remain provisional, and enquiry into both physical and psychological aspects should continue. Includes: conversion hysteria conversion reaction hysteria hysterical psychosis Excludes: malingering [conscious simulation] (Z76. The amnesia is usually centred on traumatic events, such as accidents or unexpected bereavements, and is usually partial and selective. The extent and completeness of the 123 amnesia often vary from day to day and between investigators, but there is a persistent common core that cannot be recalled in the waking state. The affective states that accompany amnesia are very varied, but severe depression is rare. Perplexity, distress, and varying degrees of attention-seeking behaviour may be evident, but calm acceptance is also sometimes striking. Young adults are most commonly affected, the most extreme instances usually occurring in men subject to battle stress. Purposeless local wandering may occur; it is usually accompanied by self-neglect and rarely lasts more than a day or two. Diagnostic guidelines A definite diagnosis requires: (a)amnesia, either partial or complete, for recent events that are of a traumatic or stressful nature (these aspects may emerge only when other informants are available); (b)absence of organic brain disorders, intoxication, or excessive fatigue.
It is difficult for blood to medicine vial caps buy meclizine 25 mg lowest price return to symptoms glaucoma purchase 25mg meclizine fast delivery the experiencing increased intracranial pressure medicine woman strain buy meclizine on line. Depending on the experiencing another cardiac event that exact location penetrating neck trauma can requires immediate treatment medicine syringe meclizine 25mg for sale. His vital signs cause significant injury to underlying and skin perfusion are suggestive of cardiogenic structures. Based on the presenting vital signs, shock, and the patient may require fluid immediate actions to address airway, breathing, resuscitation or vasopressors to treat and circulation are required. If vital signs are outside the emotional, and legal needs must be addressed accepted parameters, they may be considered in a timely manner. The mechanism of physical exam, this young man will be injury represents a high-risk situation. His left discharged to home with a prescription and upper-quadrant pain could be due to a splenic appropriate discharge instructions. This instructed to come back to the emergency patient’s vital signs are stable, so there is no department for a wound check. He will be need for immediate lifesaving intervention, but examined and discharged to home. From the history, signs of shock, hypotension tachycardia, and it sounds like the hockey player experienced a tachypnea. On arrival in the emergency interventions to address airway, breathing, and department, he will require immediate circulation. At a minimum, she will need to home with a prescription and appropriate two resources: hand-held nebulizer treatments discharge instructions. This patient will Answers require a physical exam then a tetanus booster, which is not considered a resource. This patient is require an x ray of his clavicle and suturing of exhibiting signs of central retinal artery his arm laceration. In addition, he may need a occlusion, which represents an acute threat to tetanus booster, but that does not count as a loss of vision. The application of a splint and crutch 8/10, but the triage nurse can intervene by walking instructions are not counted as applying a sling and providing ice to decrease resources. The trauma team seen immediately, and interventions to prevent needs to be in the trauma room and ready to liver damage must be initiated. At the same aggressively manage this 21-year-old with a time she needs to be placed in a safe, secure single gunshot wound to the left chest. He will environment and monitored closely to prevent require airway management, fluid resuscitation harm to herself. An x ray is indicated to overdose is a high-risk situation, and wellbutrin rule out a fracture, —one resource. Sickle cell disease suicidal and also needs to be monitored closely requires immediate medical attention because for safety. Rapid analgesic year-old male is probably showing signs of management will help prevent the crisis from alcohol withdrawal, a high-risk situation. He is progressing to the point where hospitalization restless, tremulous and tachycardic. Abdominal pain, loss of appetite, and nausea in a 10-year-old who has not had a bowel 16. This surgery consult, maybe an enema—but at least patient is a danger to herself and needs to be two resources. The patient will asthmatic is tiring out and will need immediate need a history and physical exam and then will lifesaving intervention that will require at a be discharged to home with a prescription. An minimum a nurse and physician at the bedside oral dose of his blood pressure medication does immediately. You protocols regarding when and by whom vital would not use your last open bed for her. A chest pain patient that is pale, diaphoretic, hypotensive, or bradycardic will A–1 Appendix A. Her right upper extremity is in a short arm cast; digits appear tense, swollen and Post-Test Questions and Answers ecchymotic. A 40-year-old male presents to triage with usually healthy but has “not been eating well vague, midsternal chest discomfort, occurring lately. This morning, he the baby is “hot”" and gave acetaminophen two reports a similar episode, which has now hours prior to arrival. Currently complains of mild nausea, blanket, eyes open, appears listless, skin hot but feels pretty good. Respirations are He is alert, with skin warm and dry, does not regular and not labored. A 22-year-old female on college break presents lower quadrant pain, 5/10, all day. Pain is to the triage desk complaining of sudden onset associated with loss of appetite, nausea and of feeling very sick, severe sore throat, and vomiting. A 28-year-old male arrives with friends with a sudden onset of left arm weakness, slurred chief complaint of a scalp laceration. Symptoms states he was struck in the head with a baseball began 2 hours prior to arrival. Left upper-extremity weakness otherwise alert and oriented to person, place, noted with 2/5 muscle strength. There is a 5-cm laceration to the scalp near his left ear with bleeding controlled. A 60-year-old male complains of sudden loss of vision in the left eye that morning. He daughter states that her mother fell yesterday is unable to ambulate due to foot and back and fractured her arm. The patient appears pale, ominous sign, and may demonstrate an slightly diaphoretic, and in mild distress. Patient is sitting upright in common in children, but may occur in adults; a wheelchair. A 12-year-old female is brought to triage by her access of an airway (preferably in the operating mother who states her daughter has been weak room). Denies fever, signs of an acute stroke and requires immediate abdominal pain, or diarrhea. The child is awake, lethargic, therapy, he may still be in the time window of and slumped in the chair. A 40-year-old male presents to triage with a gradual increase in shortness of breath over the 4. He is in the few true ocular emergencies and can occur moderate respiratory distress, skin warm and in patients with risk factors of coronary artery dry. Since she is able to eat ice cream, Pulse is tachycardic at a rate of 140 and he has you would not give your last open bed for this a blood pressure of 80 palpable. This patient is high-risk, due to patient requires immediate life-saving history of angina for 1 month. The patient intervention: Cutting of the cast and further complained of symptoms of acute coronary evaluation for potential compartment syndrome earlier in the morning. High risk for sepsis or severe presentation is concerning enough to be dehydration. These are symptoms with good eye contact, similar complaints, and significant for a potential cardiac ischemic a fever of 100. The temperature is not needed to accompanied or preceded by waxing and make the assessment that the baby is high risk. An immediate the presence of lethargy and a sunken fontanel electrocardiogram is necessary. Onset is rapid, with a high temp (usually Signs of acute appendicitis include mild-to >101. Patients do not have a harsh cough appetite, nausea, vomiting, low-grade fever, associated with croup, often assume the tripod muscle rigidity, and left lower quadrant A–3 Appendix A. Frequently Asked Questions pressure that intensifies the right lower hypertension, trauma, illegal drug use, and quadrant pain.
Just seeing smoking as an addiction that may have horrible consequences is a depressing notion symptoms carbon monoxide poisoning cheap generic meclizine uk, and fighting it doesn’t raise your self-esteem treatment 99213 purchase meclizine 25 mg with amex. Even if you succeed in quitting this habit medications side effects trusted meclizine 25mg, you still haven’t regained your inner sense of freedom and are likely to medications 8 rights order meclizine once a day develop an addiction to something else, like eating sweets, drinking alcohol or having sex. Instead of waging a war against your anxiety or poor self-confidence, all you need to do is increase that sense of inner freedom to make your own choices in life. If understood and dealt with properly, smoking can be one of the most important things that has ever happened to you. It can lead you to adopt an entirely new way of thinking, thus reshaping your destiny. If you are a smoker and wish to give up the habit, you first need to understand that your addiction is not an accidental mistake you made during one of your lower moments in life. It is likely to stay with you or change into another addictive habit until that day when you will have acquired the ability to refer all power of fulfilling your desires back to yourself. Giving up smoking is not about quitting one addictive habit just to adopt another one; it is about recovering your sense of free will. To use one’s willpower to fight an undesirable habit is defeating its purpose and likely to backfire because fighting something is based on the premise that you are being attacked or in some sort of danger. With what we know today about the powerful mind/body connection, the fear that underlies the fight against an addiction is enough to keep the cells of the body jittery, anxious and dysfunctional. They can never find the peace, balance, and energy they need in order to be “happy” cells for as long as the fear of not being in control prevails in the awareness of their master. The enzyme-based messages that cells are sending to the brain and heart are simple cries for help. To “overcome” the discomfort, at least for a few moments, the host feels 208 Timeless Secrets of Health and Rejuvenation compelled to grab the next cigarette or look for another drink. Each time the discomfort reemerges, he or she feels defeated and weakened, and so the addiction carries on. They are the “ghosts of memory” who live in our subconscious and pop up every time the addictive substance is in sight or is imagined. The subsequent urge is not under conscious control, hence the feeling of “dying” for a cigarette, a cup of coffee, or a bar of chocolate. You cannot successfully exorcise the ghost of memory by throwing away your cigarettes, avoiding your smoking friends, or living in a smoke-free environment. Society has condemned the act of smoking so much that many smokers already feel deprived of that sense of personal freedom they need to feel in order to make their own choices in life. If you are a sensitive person, be aware that a nagging spouse, a doctor, and the warning written on cigarette packs that smoking is harmful to your health may make you feel ridden with guilt. When all of this external pressure succeeds in making you give up smoking, you will continue to feel deprived of your free will and, therefore, look for other more socially acceptable forms of addiction. Making Smoking a Conscious Choice We all remember our childhood days when our parents told us not to eat chocolate before lunch or would not allow us to watch television when we wanted. The subconscious mind reacts negatively when it is deprived of its ability to make choices or when it feels forced to do something against its will. Disappointments resulting from not being able to fulfill one’s desires can add up and lead to an inner emptiness that wants to be filled. Smoking is simply a subconscious rebellion against the external manipulation of our freedom to choose what we want, and it appears to fill that uncomfortable space within, at least for a little while. However, this inner lack can only subside permanently when we have regained the freedom to make our own choices. You must know that you are free to smoke whenever you like and however often you like. If you have a cigarette and a match to light it, you will certainly find a way to smoke it, too. The unconscious association of smoking, with all the other “don’ts” in your past, will be negated by accepting your desire to smoke. I felt like a criminal because the law said I was only allowed to smoke when I was sixteen years old. Years of hiding my “secret” from my parents and my teachers left me with no other choice but to continue smoking until I felt I had a choice. When I finally got the legal permission to smoke, I lost interest and chose to quit. The first and most important step to quit smoking is to give yourself permission to smoke. Guilt from the act of smoking will only prevent you from gaining satisfaction and urge you to have another cigarette that may “at last” give you what you have been looking for. But you are not really looking for the short sensation of satisfaction that smoking provides but for the lost freedom to make your own choices in life. By trying to avoid lighting up, you also deprive yourself of this potential satisfaction. Symptoms may include depression, lack of interest in life, sleeplessness, anger, nausea, ravenous hunger, obesity, cardiovascular disease, lack of concentration, and shaking. However, these symptoms can only manifest if you believe that you have been deprived of your freedom to smoke. Contrary to general belief, to give up smoking you do not need to abolish your desire to smoke. You will start giving up the habit automatically once you choose not to follow your desire to smoke each and every time you have it (the desire to smoke). This will take the fuel out of your subconscious, rebellious mind and stop you short of becoming a victim of external forces, situations or people. It may even be a good idea to encourage your desire to smoke by keeping your cigarette pack in front of you, smelling it from time to time. Watch other people around you light up and inhale, imagining that you inhale deeply too. Do not count the days that pass without you smoking and do not look ahead in time either. You neither need to prove to yourself nor to anyone else that you can beat this addiction. You are neither a better person if you quit, nor are you a worse person if you don’t. You will always have this choice, and you will always be only a puff away from being a smoker, just like the rest of us. The choice of using and training your free will has to be made in the ever-present moment, right now, and has to be done anew repeatedly many times each day. The longer the periods of time during which you actualize your choice not to smoke, the more quickly diminishes your urge to smoke, becoming less intense each day. Whenever the desire to smoke returns, which is possible because the ghost of memory doesn’t just leave your subconscious overnight, you are once again compelled to make a new choice. This time, however, your conscious mind finds it much easier to stick with its previous successful choice because of the newly improved self-confidence and self-esteem. Setbacks don’t exist in this program; only exercising your freedom of choice does. It will restore your power of using your free will and remove the “victim” within you. Because you have been told so many times in your life that you cannot do this or cannot do that, you began to use this belief dogma to accept your addiction as being too difficult to quit. By reclaiming your power of making conscious choices you will be able to break the self-fulfilling “I can’t” pattern in your life for good. Ending the Addiction Before you decide to stop smoking (or any other addiction), make sure that you are aware of the following points: • Make ending your addiction a priority in your life. Also, people will assume you are still smoking; this way you don’t have to prove to anyone that you are capable of quitting the habit. This will teach you to consciously accept your desire to smoke, but not always fulfill it. By choosing not to smoke each time the desire emerges, you train your mind to make conscious choices. Your addiction is a “program” that you have written in your subconscious mind and associated with such clues. Another suggestion is to smoke somewhere in the house or garden where you usually don’t smoke. This will sever the ties to your subconscious and make your decision whether to smoke or not a more conscious one.
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Special elastic bandage proved to medicine escitalopram buy meclizine line be effective (it relieves pain significantly without hampering respiration) symptoms 9dpo purchase meclizine mastercard. Costochondral inflam m ation Costochondral inflammation is characterized by jabbing symptoms vaginal cancer generic 25mg meclizine mastercard, unilateral treatment broken toe discount meclizine 25mg with mastercard, mild to moderate pain radiat ing to the back and abdomen and worsened by deep breathing and physical exertion; pain is influenced by change of posture. Costochondral inflammation occurs as a result of acute viral respiratory infection or physical overexertion and lasts up to several months. Differential diagnosis includes Tietze’s syndrome, which is characterized by the thickening of costal cartilages. Costochondral inflammation is most often diagnosed in women (25-44 years old) the pain is thought to be due to inflammation of the 3rd or 4th left costochondral junction. Suggestive Clinical Practice Guidelines for General Practitioners 29 Chest Pain history includes pain with use of chest wall muscles. In addition, the pain may occur at rest or with deep inspiration, and there is usually no history of recent trauma or muscular exertion. The characteristic physical finding is tenderness to palpation over a costochondral junction. If the patient has tried them, anti-inflammatory agents have often provided relief. Back pain Back pain is usually caused by spinal disease; osteoarthrosis affecting costovertebral articula tions is among the most common causes. These joints may be affected, particularly during ster notomy with wound edges spread wide apart. Acute back pain is a rare occurrence and may be caused by spinal fracture or severe vascular or visceral disease. Other causes include intervertebral disc hernias and penetrating gastric or duodenal ulcer. Treatment: if no osteoporosis and acute inflamma tion are present and if the patient is not receiving anticoagulants, chiropractic may be administered. Chest Pain in Children Although chest pain is a common occurrence in teenagers, it rarely indicates severe disease. In a number of cases, pain cause remains unknown, because it is mostly psychogenic in nature. Other causes of pain include: disorders of chest wall muscles, bones and joints; hyperventilation syndrome, bronchial asthma; pain caused by bad cough; chest, back and upper arm traumatism occurring during games or sports. In children, lung disease (pneumonia, bronchial asthma, recurrent bronchitis) and heart disease should be ruled out. Yes No Search for the site of infection Determine the form and nature of disease according to the following plan: • site of inflammation and search for neurological defect • X-ray of painful areas • laboratory tests (Dermatomyositis should be taken into account. Pain caused by myocardial ischemia should be dif ferentiated from squeezing pain in the chest and left hypochondrium caused by contraction of splenic capsule (it is a common occurrence, espe cially in unexercised children after a long-distance race). Patient has history of hypertension over the last 10 years (varying within a range of 140/80 to 150/90 mmHg). Physical examination reveals the following: No breathing movement on the left side of the chest. Auscultation: absence of breath sounds in the upper left third of the chest; accentuated res piration on the left side. Percussion: bandbox reso nance over the upper left third of the chest; vesic ular resonance over the left side. Based on the above findings, provisional diagnosis of spontaneous pneumothorax was made. Patient was injected an analgesic and hospitalized in the department of thoracic surgery, where the provision al diagnosis was confirmed. Aside from increase in severity, the pain became constant with time and was influenced by breathing, movements and change of body position in bed. She had myocardial infarction 7 years ago, followed by 2-3 transient angina episodes. Physical examination reveals the following: Breathing movements appear to be symmetrical. Palpation reveals tenderness in 4th-5th intercostal spaces and along the scapular line. Lungs: vesicular respiration on auscultation, vesic ular resonance on percussion. Clinical Practice Guidelines for General Practitioners 35 Chest Pain Abdomen is soft and painless on palpation. Neurologist’s examination was provided and resulted in confirmation of diagnosis; appropri ate treatment was administered. He notes that similar pain associated with physical exertion and emotional stress has occurred peri odically (but not frequently) over the last 8 years. Current episode of pain was related to the fact that this day the elevator was out of order and the patient had to climb the stairs to the 8th floor. When he reached the 5th floor, he suddenly felt acute pain in sternal area, which was stinging and squeezing in nature and radiated to the left fore arm. However, the pain worsened again and did not respond to repeated nitroglycerin doses. Physical examination reveals the following: Breathing movements appear to be symmetrical (respiration rate 18 breaths per minute). Differential diagnosis was performed considering exertional angina, progressive unstable angina, and acute myocardial infarction. The patient was suggested Clinical Practice Guidelines for General Practitioners 37 Chest Pain to have his district therapeutist attend him after discharge. Had the district therapeutist administered early maintenance treatment and educated the patient on specific topics of his disease, this episode would have been avoided. Pain is constant, limited to the above-mentioned area, and not influenced by breathing (deep inspiration is trou blesome). He has history of periodic episodes of pain (every 2-3 months) with fever over the last 7 8 years. Physical examination reveals the following: Breathing movements appear to be symmetrical, but shallow; abdominal participation is seen. A day later, after having temperature decreased and pain relieved, physician referred the patient to appropriate specialists and arranged for necessary laboratory testing, which confirmed the presence of collagenosis; patient was administered appropriate treatment under his physician’s supervision. Pain was accompanied by anxi ety, nausea, vomiting, and diaphoresis (clammy sweat). Patient has history of chronic gastritis (over last 6-7 years); however, because the disease caused little or no discomfort, he has never been tested and treated. Before calling his physician, the patient took an analgesic (sedalgine) and nitroglycerin, which gave no relief. Physical examination reveals the following: Clinical Practice Guidelines for General Practitioners 39 Chest Pain Patient is restless; skin and visible mucosa are pale; clammy sweat is observed. She notes that during the last 3 days her right calf muscles grew swollen and became painful. She believes herself to have no illness except mild smoker’s bronchitis (she smokes one pack of ciga 40 Clinical Practice Guidelines for General Practitioners Chest Pain rettes a day). Physical examination reveals the following: Breathing movements appear to be symmetrical (respiration rates— 18 breaths per minute). He has no history of such a pain, and before this episode had believed himself to be in good health. Physical examination reveals the following: Patient is anxious, with pale skin and clammy sweat. Clinical Practice Guidelines for General Practitioners 41 Chest Pain Abdomen is soft and painless on palpation. Five years ago “cardiac murmur” was occasionally identified during a routine examination; however, further testing was not performed. Abdomen is 42 Clinical Practice Guidelines for General Practitioners Chest Pain soft and painless on palpation; hepatomegaly is identified. Breathing movements appear to be symmetrical; vesicular respiration is heard on auscultation. Cardiovascular system: Heart is not enlarged on percussion; apex beat is hyperdynamic.