An interactive case presentation during the monthly meeting of Early-career psychiatrists in Jeddah, SA. Basically, a case managed and supervised clinically by Dr Shokry Alemam, MD
Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.
Assessing and Treating Clients With Psychosis and Schizophrenia .docxcargillfilberto
Assessing and Treating Clients With Psychosis and Schizophrenia
Delusional Disorders
Pakistani Female With Delusional Thought Processes
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1,#2,#3
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
CONCLUSION: Also include how ethical considerations might impact your treatment plan and communication with clients
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so. She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.Client admits that she stopped taking her Risperdal about a week after she .
An interactive case presentation during the monthly meeting of Early-career psychiatrists in Jeddah, SA. Basically, a case managed and supervised clinically by Dr Shokry Alemam, MD
Depression is a common illness worldwide, with an estimated 3.8% of the population affected, including 5.0% among adults and 5.7% among adults older than 60 years.
Assessing and Treating Clients With Psychosis and Schizophrenia .docxcargillfilberto
Assessing and Treating Clients With Psychosis and Schizophrenia
Delusional Disorders
Pakistani Female With Delusional Thought Processes
Examine Case Study: Pakistani Woman with Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1,#2,#3
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
CONCLUSION: Also include how ethical considerations might impact your treatment plan and communication with clients
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her since she was 9 years old). She presents to your office today following a 21 day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.During today’s assessment, she appears quite calm, and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She tells you that she knows this because the television is telling her so. She currently weighs 140 lbs, and is 5’ 5”
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down.You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits.Client admits that she stopped taking her Risperdal about a week after she .
PRN Medications; its justified use: by Dr Prithvi PuwarPrithvi Puwar
The presentation is mentioning the details of PRN medications, its common use, the common problems occured by erroneous medications side effects ...A must to know by duty doctor, registrars and nurses. Most of the presentation slides are in interactive way.
This presentation highlights an actual conversation between a patient hospitalized to be treated for organophosphate poisoning, and a PharmD student. the PharmD student interviews patient to obtain complete history.
this presentation will be very helpful to PharmD students and give them a practical example of interviewing patients giving them an outline and a general idea about conducting patient interviews to obtain history
Melissa Hinkhouse
Advanced Pharmacology NURS-6521N-43
Professor Dr. Vicki Gardin
Discussion Board Week 1-Original Post
11/30/2020
I have worked in an outpatient behavioral health clinic for the past seven years with many different providers. I live in a rural community, many patients wait six to twelve months to be seen. Patients being treated for Attention Deficit Disorder must be officially tested before being seen by a Psychologist. For this discussion board post, I have changed the name of my patient to Paul to ensure patient confidentially. The provider I worked with this particular patient will also be referred to as PMHNP to ensure provider confidentiality.
Paul was a ten-year-old Caucasian male referred to our clinic diagnosed per DSM criteria, confirmed via Psychologist testing with ADHD. When he saw the Psychologist, he was also diagnosed with mild depression and anxiety. He struggled with concentration, hyperactivity, impulse control, and disorganization. He presented to his appointment with his mother and father, clean, well-nourished, pleasant, interactive with staff, reported no medication allergies, current medication Zyrtec for seasonal allergies. Paul just had his well-child exam and is current on vaccinations and his primary care provider completed lab work to include CBC, CMP, TSH, Vit D, B12, and A1C, all have returned normal. Family history reported father has a history of ADHD (never medicated), brother has a history of depression and anxiety (never medicated treating with psychotherapy), no other significant family history to report. Paul’s current weight at his appointment was 30kg.
PMHNP spent one hour with Paul and his parents for the initial new patient appointment (Thursday). It was decided Paul would be prescribed Strattera (atomoxetine) 40mg once a day for one week then increase to 80mg once a day. I returned to work on Monday and received a call from Paul’s mom, she said he was acting strange. He was tearful, had been in his room with the door closed for most of the weekend, she stated on Sunday she went into his room and he was crying and said he was just thinking about dying and his parents dying. She stated he had already had his meds Sunday so she kept him with her that entire day and made Sunday night a campout night in the Livingroom so he would think it was fun and she could keep a close eye on him. I had a cancelation that morning for him to come to see PMHNP and he was in to see her within twenty minutes and removed from Strattera. His parents decided medications were no longer the route they wanted to try for treatment and a referral was made for psychotherapy.
The only medication Paul takes on occasion is Zyrtec which is in an antihistamine drug class, Strattera is a selective norepinephrine reuptake inhibitor; there is no known drug interaction between the two medications. Reflecting on his age and the medication, Strattera has a black box labeled for suicidal ideation with adolescents dia.
Delusional DisordersPakistani Female with Delusional Thought ProLinaCovington707
Delusional Disorders
Pakistani Female with Delusional Thought Processes
BACKGROUND
The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.
Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.
During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so.
She currently weighs 140 lbs., and she is 5’ 5.
SUBJECTIVE
Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.
A review of her hospital records shows that she received a medical workup from a physician, who reported her to be in overall good health. Lab studies were all within normal limits.
Client admits that she was tolerating her Risperdal well but stopped taking about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.
MENTAL STATUS EXAM
The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.
You administer the PANSS which reveals the following scores:
-40 for the positive symptoms scale
-20 for the negative symptom scale
-60 for general psychopathology scale
Diagnosis: Schizophrenia, paranoid type
RESOURCES
PANSS Scale. Available at: http://egret.psychol.cam.ac.uk/medicine/scales/PANSS
§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Po ...
Approach to right iliac fossa(RIF) painasifiqbal545
Approach to right iliac fossa(RIF) pain.FULL DISCUSSION ON APPENDICITIS WITH OTHER DIFFERENTIAL DIAGNOSIS OF IT. AS WELL AS CLINICAL REASONING DIAGNOSIS AND TREATMENT.
IMMUNIZATION/VACCINATION(BOTH CHILD AND ADULT) WITH ALL UPDATESasifiqbal545
IMMUNIZATION/VACCINATION(BOTH CHILD AND ADULT) WITH ALL UPDATES AND DETAILS WITH FREQUENTLY ASKED QUESTIONS WITH DISCUSSION ON NEWEST VACCINES. ALSO DISCUSSION ON COLD CHAIN ETC.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. HISTORY
Pt seen in my psychiatry rotation ,in male ward(khasab hospital)
37 yrs old indian man,with past h/o multiple episodes of
depression,last episode was 1 yrs back.never had manic or hypomanic
episodes.
His wife said his diagnosis was schizophrenia
He has 2 wks h/o acute behavioral change .
Noted to be overhappy, overconfidant and overactive.But at times
noted to be very irritable and verbally aggressive.
He works as an electrician.he suddently went to the indian school in
khasab and started to give lectures to the students few days ago.
3. CONT..
he suddently went to airport in intention to go to india
.but he did not book a ticket.
He had poor sleep.
No h/o confusion or disorientation to time ,place or
person.
His brother brought medication from india ,3 days
ago,has been on olanzapine 7.5 mg HS for past 2 days.
Both pt ,his wife and his brother denied smoking
cigarette,alcohol intake or drug abuse.
He has been in khasab for years.
5. Mental state
examination
Pt was very argumentaive
Irritable
Talking with an overconfident manner with some grandiosity
but no grandiose delusion at time of assesment
Not noted to be hallucinating at time of assesment
Insight was poor
8. Rationale of
investigation
• CBC-certain anticonvulsant may cause bone marrow suppression.
Eg. carbamazepine
• Lithium may cause reversible increase in WBC count .
• RBS-atypical antipsychotic can cause problem with glucose
regulation.
• RFT-treatment with lithium can cause renal and electrolyte
problem.
• TFT-hyperthyroidism ,and sometimes hypothyroidism can cause
psychiatric symptoms
• LFT-some antipsychotic can cause liver dysfunction
• You can do ECG to take as a baseline because some antipsychotic
and antidepressant can cause increase QT interval eg. amitriptyline,
risperidone ,haloperidol.
• You can do urine for drug screed if you suspect drug abuse
• You can do EEG if you suspect underlying epilepsy.
9. Treatment
Initial rx plan was to give haloperidol inj (5
mg im ,max 3 doses in 24 hours)and
promethazine inj 25 mg im maximum 3 doses
in 24 hours) for agitation sos.
Olanzapine increased to 10mg
To start sodium valporate as mood stabilizer
,gradually
10. What we
faced in
morning
rounds...
• Pt said he slept for few hours ,after he has taken
olanzapine tab 2 am at night,he went outside the ward to
the parking area wanted to go home.brought back by
secuirity and received promethazine inj.he slept again at
5 am,he woke at 9 am prior to our morning rounds.since
that time noted to be very irritable ,argumentative,and
asking to go home .his agitation escalated.staff
attempted to administer sos injection but was very
difficult due to high level of agitation.MSE:pt was very
agitated,standing at bay area of the ward.his agiatation
increased when any staff tried to speak with him.he was
overfamiliar and socialy disinhibited with other co-
patients and attendants,contacted to al masarra hospital
regarding transferring pt for admission there and a bed in
acute male ward has been booked for the pt.
11. Cont..
• Pt abscoded again from the hospital by this
time,brought back by police.staff was unable to
administer the injections even in the presence of
secuirity staff and police officers .pt refused
injection and was very aggressive .
• Pt's sponsor and pt's brother refused transfer to al
masarra hospital despite repeated explanation to
them regarding risk of premature discharge and
expected negative consequences.also
informed them we can't keep the pt in our
hospital anymore as he poses great risk to
others and our ward is not prepared for such
cases.both pt 's brother and
sponsor signed LAMA form for refusal to transfer in
the presence of PRO and male ward staff nurse .
14. Some home
message for
antipsychotic
• In pregnant women you can use lamotrigine or
electroconvulsive therapy. because carbamazepine
,sodium valproate these drugs can cause congenital
anomaly. atypical antipsychotics cross placenta but
no severe side effect noted, almost all of them
pregnancy category C, use them with caution if
benefits outweighs risk, preferably consult with
psychiatrist for pregnant and breastfeeding patient
• In breastfeeding patient you can use olanzapine or
quetiapine can be used .haloperidol and risperidone
can be used under supervision of psychiatrist only.
• For depressive episode in bipolar disorder fluoxetine
and olanzapine combination can be used .
15. Some home message
• For sodium valproate dosages-start with 200 mg tds ,then increase gradually ,effective
maintenance dosage between 1000 mg to 1500 mg /day in divided dosage
• Antidepressants are not used in bipolar disorder except fluoxetine and olanzapine
combination.
• Be cautious about use of lithium in bipolar disorder, because of narrow therapeutic
window, so need facility of frequent monitoring of serum level. most of the psychiatrist
now using other mood stabilizer like sodium valproate.
• Treatment option for bipolar disorder is benzodiazepines for acute agitation, antimanic
drug like lithium. anticonvulsant /mood stabilizer like sodium valproate and atypical
antipsychotics .of course not all together,it varies patient to patient .
