By F. Temmy. Massachusetts School of Professional Psychology. 2019.

Stop the ritual of tracing colonised people’ cheap zudena master card erectile dysfunction pills at gas stations, British Medical Journal 314(7081): 665–6 buy 100 mg zudena amex erectile dysfunction drugs australia. Clarke (eds) Cardiovascular Intensive Care Nursing , Edinburgh: Churchill Livingstone: 91–110. Use in connection with any form of information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed is forbidden. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid free paper Springer is part of Springer ScienceþBusiness Media (www. Readers should consult other resources before applying information in this manual for direct patient care. The author, editors, and publisher of Approach to Internal Medicine cannot be held responsible for any harm, direct or indirect, caused as a result of application of information con tained within this manual. Confessio Medici, Stephen Paget, 1909 The third edition of Approach to Internal Medicine builds upon previous efforts to create a practical, evidence based, and concise educational resource for everyday clinical use and examination preparation. Approach to Internal Medicine now has an expanded repertoire of over 250 internal medicine topics, classified under 17 subspecialties. With the input of a new editor and publisher, we were able to significantly expand and update the content and substantially improve the layout, while maintaining the same conciseness and practicality found in previous editions. Under each topic, the sections on differential diagnoses, investigations, and treatments are designed for the rapid retrieval of high yield clinical information and can be particularly useful when one is all alone assessing apatient at3 o’clock inthe morning. Other sections containmanyclinicalpearls thatareintended to help one to excel in patient care. We also included many comparison tables aimed at highlighting the distinguishing features between various clinical entities and numerous mnemonics (marked by w). For this new edition, we are very fortunate to have recruited a new associate editor, Dr. Alexander Leung, who brings with him a wealth of knowledge and outstanding commitment to medical education. We are most grateful to our section editors and contributors for their meticulous review of each subspecialty, providing expert input on the most up to date information. We would also like to take this opportunity to thank Jean Claude Quintal as a resident reviewer and the Canadian Federation of Medical Students for its support of the previous edition. Finally, we would like to thank all previous and current users of this manual for their support and feedback. We are pleased that Springer has taken this title under its direction and has helped to improve its quality in preparation for international release. We would particularly like to thank Laura Walsh, senior editor, and Stacy Lazar, editorial assistant, from Springer for their expert guidance and support throughout this mammoth project from design to production. Anderson Cancer Center, for believing in this work and making this collaboration possible. While every effort has been made to ensure the accuracy of information in this manual, the author, editors, and publisher are not responsible for omissions, errors, or any consequences that result from application of the information contained herein. Verification of the information in this manual remains the professional responsibility of the practitioner. Readers are strongly urged to consult other appro priate clinical resources prior to applying information in this manual for direct patient care. This is ix x Preface particularly important since patterns of practice and clinical evidence evolve constantly. We welcome any constructive feedback to help make this manual a more accurate, practical, comprehensive, and user friendly resource. Consider leuko sodes of fever, dyspnea, and productive cough triene antagonists or inhaled glucocorticoids if (brownish sputum). Other considerations include the distance between the top of thyroid cartilage need for non invasive mechanical ventilation and and suprasternal notch atend ofexpiration. Constrictive bronchiolitis (late, fibrotic, con Related Topics centric) is not responsive to glucocorticoids Cryptogenic Organizing Pneumonia (p. Not enough evidence to suggest smoking, cancer (high suspicion of occult malig any of the rules as superior. Clinical gestalt of nancy in patients who develop pulmonary embo experienced physician similar to use of rules. Unfractionated be very helpful as it provides clues to other potential heparin may be used concurrently diagnoses/pathologies as well. Treat by lung re expansion, peritoneal fluid into pleura because of negative sometimes requiring thoracotomy with decortication intrathoracic pressures and diaphragmatic defects. If high probability, sensory loss, decreased radial and brachial pulses, thoracotomy with resection or video assisted thora pallor of limb with elevation, upper limb atrophy, coscopy (for patients who cannot tolerate thoracot drooping shoulders, supraclavicular and infraclavi omy medically and physiologically) cular lymphadenopathy. Idiopathic pulmonary fibrosis (steroids plus clubbing (idiopathic pulmonary fibrosis, asbestosis, either azathioprine or cyclophosphamide). Perform respiratory and nal seizures, rapid eye movement behavior disorder cardiac examination (hypertension and pulmonary hypertension, restrictive lung disease). Treatment pentin, clonazepam, and oxycodone if precipitated options include respiratory stimulants, ventilatory by pain. If improvement >12% and 200 mL post bronchodilator, consider diagnosis of asthma (reversibility). As illustrated by the man restrictive disease below, scooping of the inspiratory curve (i. Majority of tears found in ascending History aorta right lateral wall where the greatest shear force Hypertension 1. Pulse defi absent or asymmetric peripheral pulse, limb cit or focal neurological deficits greatly increase ischemia likelihood of dissection. Type B (medical blood aorta, blurring of aortic margin secondary to local pressure control). Indicated if lar dysfunction with extensive regional wall motion cardiogenic shock with hemodynamic instability. Dia stent restenosis is due to fibrosis of coronary betic patients and those with reduced left ventricular vasculature and usually happens 3 months post function derive more benefit from bypass surgery procedure. A pulsus paradoxus >10 mmHg among patients with a pericardial effusion helps distinguish those with cardiac tamponade from those without. While the findings of this study are useful when assessing dyspneic patients suspected ofhavingheart failure, no individual feature issufficientlypowerfulinisolationtoruleheartfailure inorout.

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Shiatsu This is a deeply relaxing therapy originating in Japan that provides stimula- tion by using the fingers and palm of the hand to apply pressure and gentle stretches to the meridians discount zudena american express cannabis causes erectile dysfunction. It consists of a whole body treatment order zudena 100 mg mastercard impotence from stress, as it is believed that a disorder in one area can have effects elsewhere on the body. It is similar to both Traditional Chinese medicine | 151 acupuncture and acupressure in its effects but uses a glowing wick instead of needles or fingertips as the source of stimulation for the acupoints. Tradi- tionally moxa is the dried leaves of Artemisia vulgaris and Artemesia argyi and other species of mugwort, made into various forms including: • punk – loose moxa, rather like green cotton-wool • moxa rolls – similar to cigars in appearance • moxa cones. Another method is for a small moxa cone to be placed on the blunt end of an acupuncture needle while it is in place. It is lit at its apex and burnt down until the patient is able to feel the heat; it is then removed. Chinese herbal medicine In the west it is quite normal to equate the word ‘herbal’ with something that grows in the garden. Certainly most Chinese herbal remedies are made from plant material, but others are of mineral or animal origin, e. In China and other Asian countries the practice is still wide- spread, but it has been largely discontinued elsewhere after action by regula- tory authorities with enthusiasm that may occasionally be misplaced. The famous highly aromatic salve marketed around the world known as Tiger Balm was once the subject of a dawn raid of Chinese herbalists by police in Manchester. They thought that they had uncovered the illegal use of parts from a protected wild animal. There were a few red faces when it was realised that the title merely referred to the nickname of the brand owner! History China’s greatest materia medica (Pen Ts’ao) was published by Li Shizhen in 1578. Secret recipes (also known as ‘prepared medicines’) were the equivalent of modern patent medicines. By the time of the Ming dynasty (1368–1644) more than 60 000 formulae had been recorded in the 1406 book entitled Formulas of Universal Benefit (Pu Ji Fang). In recent years many of these formulae have passed into public usage, but there may be as many as 5000 licensed patent medicines still circulating in China. The most famous factory is at the Tong Ren Tang pharmacy in Beijing, which has been operated by the same family since the late seventeenth century. These are: • cooling • diaphoresis • elimination • emesis • mediation • purging • tonification • warming. Traditional Chinese medicine | 153 Categorisation of Chinese herbs Chinese herbs may be categorised according to: • the four natures • the five tastes • the meridians. The herbs are ascribed qualities ranging from cold (extreme yin), cool, neutral to warm and hot (extreme yang), and are often used in combination according to the deficiencies or excesses of these qualities in the patient. The five tastes The five tastes are: • Pungent: pungent herbs are often used to generate sweat and to direct and vitalise qi and the blood • Sweet: sweet-tasting herbs are often used to tonify or harmonise bodily systems • Sour: sour tasting herbs are most often used as astringents • Bitter: bitter tasting herbs are used to dispel heat and purge the bowels • Salty: salty tasting herbs are used to soften hard masses as well as purge and open the bowels. In other forms of herbal medicine, especially western herbal medicine, herbs are often delivered singly or combined into very small formulae of herbs with the same function. In contrast, Chinese herbalists rarely prescribe a single herb to treat a condition. Medicinal substances are combined to: • increase therapeutic effectiveness by synergy • reduce toxicity or adverse reactions • accommodate complex clinical situations • alter the actions of the substances. A typical Chinese herbal formula usually comprises the following components:154 • The main ingredient, which treats the main disease • The associate ingredient, which assists the main ingredient • The adjuvant, which acts as an enhancer of the main ingredient, and moderates or eliminates the toxicity of other ingredients; it may also have an opposite effect to the main ingredient to produce supplementary benefits • The guide ingredient (or envoy), which focuses the actions of the formula on certain meridians or areas of the body, or harmonises and integrates the actions of the other ingredients. Traditional Chinese medicine | 155 Presentation When herbs are prescribed for individual patients the practitioner weighs out a day’s dosage of each herb and combines them in a bag. The boiling process takes from 30 minutes to 60 minutes, and portions of the resulting decoction are consumed several times during the day. Another modern way of delivering herbs is through granulated herbs, which are highly concentrated powdered extracts. These powders are made by first preparing the herbs as a traditional decoction, after which the decoction is dehydrated to leave a powder residue. Practitioners can mix these powders together for each patient into a custom formula. The powder is then placed in hot water to recreate the decoction, which eliminates the need to prepare the herbs at home, but still retains much of the original decoction’s potency. Example of a prescription An example of the ingredients for a dried herb prescription is shown in Figure 6. Chinese patent medicines Pre-made formulae are available as pills, tablets, capsules, powders, alcohol extracts, water extracts, etc. Most of these formulae are very convenient because they do not necessitate patient preparation and are easy to take. These products are usually not as potent as the traditional extemporaneous Traditional Chinese medicine | 157 preparation of decoction described above. They are not ‘patented’ in the western sense of the word because there are no exclusive rights to the formula. All Chinese patent medicines of the same name have the same proportions of ingredients. A medicine known as ‘four gentleman decoction’ (si jun zi tang) is an example of such a product. The formula comprises: • Main herb: Radix panax ginseng (ren shen), to enhance spleen qi • Associate: Rhizoma atractylodis macrocephalae (bai zhu), to strengthen the spleen and dry off the ‘dampness’ • Adjuvant: Sclerotium poriae cocos (fu ling), to assist the main and associate herbs • Guide: Radix glycyrrhizae uralensis (zhi gan cao), to harmonise the other three herbs and regulate spleen qi. Under the Drug Administration Act 2001 post-marketing surveillance of adverse drug reactions is mandatory in China. Whenever an adverse reaction event occurs, the manufacturer, the medical institutions and the seller are obliged to report it. The main legislation requires that medicines placed on the market must have a licence, which requires meeting standards of safety, quality and efficacy. These licensing conditions pose inappropriate demands on most herbal medicines, because plants are chemically complex and variable, active constituents are not always known and the huge costs cannot be recouped through patenting. Under the 1968 Act, herbal remedies are exempt from the licensing requirement if either the herbal remedy is made up on the premises from which it is supplied, after a one-to-one consultation (Section 6. These exemptions only apply to plant remedies, so medicines containing non-plant ingredients require a medicine licence. In recent years these provisions, which provide no specific regulation for herbal medicines, have been considered inadequate to ensure their safety and quality. There are a number of reasons including: adverse effects from some herbal ingredients (natural does not mean safe); misidentification of some Figure 6. Traditional Chinese medicine | 159 herbs and occasional substitution of toxic for safe species; illegal inclusion of prescription-only drugs or heavy metals in some ‘herbal’ medicines; microbial contamination; and discovery of problematic herb–drug interactions. This establishes a registration scheme for industrially produced over-the-counter herbal medicines, under which manufacturers have to demonstrate safety and quality, but not efficacy. Quality is guided by European good manufacturing practice, and safety is protected by requiring evidence of at least 30 years of safe use, of which at least 15 years must be within the European Community. There is a lead-in time to allow manufacturers and suppliers to make the necessary adjustments, but after 2011 any over-the-counter herbal product that is not registered under this scheme will be illegal. This lead time is, however, only for products that were on the market before April 2004.

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At the end of the chain order generic zudena online erectile dysfunction doctor in pune, two positively charged hydrogen molecules combine with two electrons and an atom of oxygen to form water cheap zudena 100mg overnight delivery erectile dysfunction urethral inserts. Respiration Lipid metabolism only requires portions of the processes involved in carbohydrate metabolism. Lipids contain about 99 percent of the body’s stored energy and can be digested at mealtime, but as people who complain about fats going “straight to their hips” can attest, lipids are more inclined to be stored in adipose tissue — the stuff gen- erally identified with body fat. Those reactions continue to strip two carbon atoms at a time until the entire fatty acid chain is con- verted into acetyl CoA. Part I: Building Blocks of the Body 18 Protein metabolism focuses on producing the amino acids needed for synthesis of pro- tein molecules within the body. But in addition to the energy released into the electron transport chain during protein metabolism, the process also produces byproducts, such as ammonia and keto acid. The liver converts the ammonia into urea, which the blood carries to the kidneys for elimination. One last thing: That severe soreness and fatigue you feel in your muscles after strenu- ous exercise is the result of lactic acid buildup during anaerobic respiration. Chapter 1: The Chemistry of Life 19 Check out an example question on metabolism: Q. The part of metabolism that involves creating compounds the body needs is called a. The Krebs cycle Chapter 1: The Chemistry of Life 21 Answers to Questions on Life’s Chemistry The following are answers to the practice questions presented in this chapter. The atomic weight of 39 tells you the number of protons plus the number of neutrons: 39 – 19 = 20. The first orbit has the maximum two electrons, and the second orbit has the maximum eight electrons. That makes ten electrons in the first two orbits, leaving only four for the third, outermost orbit. The first few letters of the word “hydroxide” are a dead giveaway that there’s a hydrogen atom in there; plus hydroxide ions are negatively charged, which calls for that extra electron. If the atoms had gained or lost electrons, it would be an ionic bond, but here they’re sharing — valiantly cohabiting, if you will. This is true whether an atom fills its outer shell by sharing, gaining, or losing electrons. Being such large molecules, proteins need to be built from complex molecules to begin with. Don’t forget that the Krebs cycle, during which pyruvate is broken down, occurs in the mitochondrion. Recall that during aero- bic exercise, you’re trying to circulate oxygen to your muscles. The other answers are incorrect because glycolysis takes place in the cytoplasm, and anaerobic respiration isn’t one of the three cellular respiration processes. Just as you can’t power a lamp with a lump of coal, cells can’t use glucose directly. Chapter 2 The Cell: Life’s Basic Building Block In This Chapter Breaking through the cell membrane Aiming for the nucleus Sorting through what’s inside the cell Putting together proteins made to order Following the cell cycle ytology, from the Greek word cyto, which means “cell,” is the study of cells. Every living Cthing has cells, but not all living things have the same kinds of cells. Eukaryotes like humans (and all other organisms besides bacteria and viruses) have eukaryotic cells, each of which has a defined nucleus that controls and directs the cell’s activities, and cytosol, fluid material found in the gel-like cytoplasm that fills most of the cell. Plant cells have fibrous cell walls; animal cells do not, making do instead with a semipermeable cell mem- brane, which sometimes is called a plasma membrane or the plasmalemma. Because human cells don’t have cell walls, they look like gel-filled sacs with nuclei and tiny parts called organelles nestled inside when viewed through an electron microscope. In this chapter, we help you sort out what makes up a cell, what all those tiny parts do, and how cells act as protein-manufacturing plants to support life’s activities. Gaining Admission: The Cell Membrane Think of it as a gatekeeper, guardian, or border guard. Despite being only 6 to 10 nanometers thick and visible only through an electron microscope, the cell membrane keeps the cell’s cytoplasm in place and lets only select materials enter and depart the cell as needed. This semipermeability, or selective permeability, is a result of a double layer (bilayer) of phospho- lipid molecules interspersed with protein molecules. The outer surface of each layer is made up of tightly packed hydrophilic (or water-loving) polar heads. Inside, between the two layers, you find hydrophobic (or water-fearing) nonpolar tails consisting of fatty acid chains. Cholesterol molecules between the phosphate layers give the otherwise elastic membrane stability and make it less permeable to water-soluble substances. Both cytoplasm and the matrix, the material in which cells lie, are primarily water. The polar heads electrostatically attract polarized water molecules while the nonpolar tails lie between the layers, shielded from water and creating a dry middle layer. The membrane’s interior is made up of oily fatty acid molecules that are electrostatically symmetric, or nonpolarized. Lipid-soluble molecules can pass through this layer, but water-soluble molecules such as amino acids, sugars, and proteins cannot. Because phospholipids have both polar and nonpolar regions, they’re also called amphipathic molecules. Part I: Building Blocks of the Body 24 The cell membrane is designed to hold the cell together and to isolate it as a distinct functional unit of protoplasm. Although it can spontaneously repair minor tears, severe damage to the membrane will cause the cell to disintegrate. It allows movement across its barrier by diffusion, osmosis, or active transport as follows: D i f f u s i o n : This is a spontaneous spreading, or migration, of molecules or other particles from an area of higher concentration to an area of lower concentration until equilibrium occurs. When equilibrium is reached, diffusion continues, but the flow is equal in both directions. Diffusion is a natural phenomenon that behaves in much the same way as Brownian motion; both phenomena are based on the fact that all molecules possess kinetic energy. They move randomly at high speeds, colliding with one another, changing directions, and moving away from areas of greatest concentration to areas of lower concentration. The rate of movement depends on the size and temperature of the molecule; the smaller and warmer the molecule is, the faster it moves. Diffusion is one form of passive transport that doesn’t require the expenditure of cellular energy. A molecule can diffuse passively through the cell membrane if it’s lipid-soluble, uncharged, and very small, or if it can be assisted by a carrier molecule. The unassisted diffusion of very small or lipid-soluble particles is called simple diffusion. The cell membrane allows nonpolar molecules (those that don’t readily bond with water) to flow from an area where they’re highly concentrated to an area where they’re less concentrated.

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These movements are slow (bradykinesia) and the patient exhibits involuntary tremors of the head and neck which may be more prevalent at rest and pill-rolling movements of the hands purchase zudena mastercard impotence natural food. Another characteristic symptoms is the masked facies (no facial expression) common in patients with Parkinson’s disease discount zudena online master card erectile dysfunction related to prostate. Dopaminergics decrease the symptoms of Parkinson’s disease by permitting more levodopa to reach the nerve terminal where levodopa is transformed into dopamine and the tremors are reduced. Dopamine agonists stimulate the dopamine receptors and reduce the symp- toms of Parkinson’s disease. However they can cause a hypertensive crisis if taken with certain foods (see Table 15-1). Spasms are caused by hyperex- citable neurons stimulated by cerebral neurons or from lack of inhibition of the stimulus in the spinal cord or at the skeletal muscles. There are two groups of muscle relaxants: centrally acting and peripherally acting. Centrally acting mus- cle relaxants depress neuron activity in the spinal cord or in the brain. They are used to treat acute spasms from muscle trauma, but are less effective for treating spasms caused by chronic neurological disorders. These drugs decrease pain, increase range of motion and have a sedative effect on the patient. Centrally acting muscle relaxants should not be taken concurrently with central nervous system depressants such as barbiturates, narcotics, and alcohol. Diazepam (Valium) and Baclofen (Lioresal) These are used to treat acute spasms from muscle trauma and for treating spasms caused by chronic neurologic disorders. Peripherally acting muscle relax- ants depress neuron activity at the skeletal muscles and have a minimal effect on the central nervous system. These are most effective for spasticity or muscle contractions caused by chronic neurologic disorders. This is also used to treat malignant hypertension which is an allergic reaction to anesthesia. Patients experience fatigue and muscle weakness—particularly in respiratory muscles, facial muscles, and muscles in the extremities. They have drooping eye- lids (ptosis) and difficulty in chewing and swallowing and their respiratory mus- cles become paralyzed which leads to respiratory arrest. They include ambenonium (Mytelase), edrophonium Cl (Tensilon), Neostigmine bromide (Prostigmin), and Pyridostigmine bromide (Mestinon). Multiple lesions of the myelin sheath that surround the nerve fibers occur that are called plaque. At times patients don’t experience symptoms and other times symptoms can become severe and debilitating. Interferonß-1B (betaseron) and interferonß-1a (avonex) These are used to reduce the frequency and severity of relapses. Copolymer 1 This drug is in clinical trials and appears to decrease the disease’s activity. Copaxone (glatiramer acetate injection) This drug reduces new brain lesions and the frequency of relapses in people with relapsing-remitting multiple sclerosis. Part of the patient’s brain that controls thought, memory, and language becomes impaired. Alzheimer’s disease affects 5% of people between 65 and 74 years of age and half of those older than 85 years. Although the cause of Alzheimer’s disease remains unknown, investigators have discovered Alzheimer’s patients have abnormal clumps of amyloid plaques and tangled bundles of fibers called neurofibrillary tangles in parts of their brain. Amyloid plaques, neurofibrillary tangles, and decreased chemical levels impair thinking and memory by disrupting these messages and causing nerve cells to die. Eventually, the patient loses mental capacity and the ability to carry out daily activities. Although there isn’t a treatment that stops Alzheimer’s disease, there are medications that provide some relief to patients who are in the early and middle stages of the disease. Tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) These drugs prevent some symptoms from becoming worse for a limited time. Tranquilizers, mood elevators, and sedatives These can help control behavioral symptoms such as sleeplessness, agitation, wandering, anxiety, and depression. Effects of Cholinergic and Anticholinergic Drugs Body Tissue Cholinergic Response Anticholinergic Response Cardiovascular* Decreases heart rate, lowers blood Increases heart rate with pressure due to vasodilation, large doses. Eye+ Increases papillary constriction, Dilates pupils of the eye or miosis (pupil becomes smaller), (mydriasis) and paralyzes and increases accommodation ciliary muscle (cycloplegia), (flattening or thickening of eye causing a decrease in lens for distant or near vision). Glandular* Increases salivation, perspiration, Decreases salivation, and tears sweating, and bronchial secretions. Bronchi (lung)* Stimulates bronchial smooth Dilates the bronchi and muscle contraction and increases decreases bronchial bronchial secretions. Striated muscle+ Increases neuromuscular Decreases tremors and transmission and maintains rigidity of muscles. Central nervous system Drowsiness, disorientation, and hallucination can result from large doses. Seventy-five percent of persons with seizures had their first seizure before 18 years of age. These include grand mal (tonic-clonic), petit mal (absence), and psychomotor seizures. Hydantoins (phenytoin, mephenytoin, ethotoin) These treat grand mal (tonic-clonic) seizures and psychomotor seizures. Barbiturates (Phenobarbital, mephobarbital, primidone) These are used for treating grand mal and acute episodes or status epilepticus; meningitis, toxic reactions, and eclampsia Succinimides (ethosuximide) These are used to treat absence seizures and may be used in combination with other anticonvulsants. Oxazolidones (trimethadione) This is used to treat petit mal seizures and may be used in combination with other drugs or singly for treating refractory petit mal seizures. Benzodiazepines (diazepam, clonazepam) These are effective in controlling petit mal seizures. Carbamazepine This is effective in treating refractory seizure disorders that have not responded to other anticonvulsant therapies. It is also used to control grand mal and partial seizures and a combination of these seizures. Valproate (valproic acid) This is used to treat petit mal, grand mal, and mixed types of seizures. It can suppress the sodium influx by binding to the sodium channel pro- longing the channel’s inactivation and preventing neurons from firing. Antipsychotics Psychosis is a disorder that is characterized by a number of symptoms. These include difficulty processing information and reaching a conclusion; experienc- ing delusions or hallucinations; being incoherent or in a catatonic state; or demonstrating aggressive violent behavior. Schizophrenia is a chronic psychotic disorder where patients exhibit either positive or negative symptoms. Positive symptoms are exaggeration of normal function such as agitation, incoherent speech, hallucination, delusion, and paranoia. Negative symptoms are characterized by a decrease or loss of motiva- tion or function such as social withdrawal, poor selfcare, and a decrease in the content of speech.

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