Another simple question with an immediate answer, which offers no doubt. It describes a patient worried about a non-existent physical defect, whose concern distresses him and prevents him from leaving the house. As a psychiatry resident, I wish the MIR questions in my specialty were a bit more thought-provoking and in-depth, although I know that the seconds you will have saved by marking the fourth one directly are very valuable.

Another simple question with an immediate answer, which offers no doubt. It describes a patient worried about a non-existent physical defect, whose concern distresses him and prevents him from leaving the house. As a psychiatry resident, I wish the MIR questions in my specialty were a bit more thought-provoking and in-depth, although I know that the seconds you will have saved by marking the [HIDDEN] directly are very valuable.

A 26-year-old single man is brought in by his family because he has been refusing to leave his home for 3 months. The reason given by the patient is the belief that he has an asymmetrical jaw and a crooked face. According to the patient, this situation is progressive and he looks more and more deformed when he looks in the mirror. He is ashamed of his appearance, so he does not want to go out, he gets very anxious when he sees his image and he cannot stop thinking about his deformity all day long. He has consulted several maxillofacial surgeons but they tell him that he does not have facial asymmetry and refer him to a psychiatrist. The patient's diagnosis is:

Major depressive disorder with delusional ideas incongruent with mood.

Who rules the roost?

Adam's mother was concerned about her 3-year-old son's hyperactivity, violence, and activity level. Adam and his mom had recently moved into a shelter for pregnant women. The rest of the residents are primarily in their early 20s, whereas Adam's mom is 42. She had found about 3 months ago that she was pregnant. This was her fourth pregnancy, second with this father, and he had recently left her when she refused an abortion. Her other children are 22 and 24 and live out of state. She has a history of opioid addiction. She had been on methadone during Adam's gestation and had recently started on buprenorphine to treat her addiction during this pregnancy as well. Adam is here today for his 3-year-old checkup and you had not seen him for a year. Mom states that he has been healthy but has become progressively active over the last year. He is very angry about his dad leaving, and according to Adam's mother "blames her" for sending him away. They are living in 1 room at the shelter, and mom is finding it increasingly difficult to keep him busy all day. When she goes out looking for a job, he is very challenging at the shelter, and she constantly receives complaints that he is "too loud" in the common rooms. She feels like she is at the end of her rope with him, he is constantly climbing, bolting from her, and taking risks.When you examine Adam, you find a robust, healthy young boy. His eye contact is good, and he is socially related but does actively explore your office. When he begins taking the instruments off your wall, his mother sits passively watching him. When he begins playing with the faucet, she half heartedly tells him to "stop" but he looks at her and continues splashing. He then begins flicking the light switch on and off in the room with no response from mom. When you ask about discipline, mom states "nothing works." When you ask about supports, she states "I have nobody except Adam and the new baby now."Adam was born after an uneventful full-term pregnancy with his mother on 100 mg methadone daily. She denies cigarette smoking, drugs, alcohol, or other medications. Urine testing throughout was positive only for opioids. Motor milestones were achieved at the appropriate time. Language milestones at the 2-year-old visit consisted of 10 single words. Now, he has a 50 single-word vocabulary but no 2-word combinations. He primarily takes whatever he wants and has a tantrum if mom cannot figure out what he desires. Adam's medical history is unremarkable. Family history is significant for drug abuse by her father and mother; mental illness in the father's family consisting of bipolar disorder in several uncles. Where do you go from here?

Madhoshi

and family try to explain to her that Aman doesn't exist. Anupama refuses to listen. Then, suddenly, Aman comes and everyone can see him. On Anupama's and Aman's wedding day Aman confesses that he is really Arpit and that he got plastic surgery. The only way that his face looks exactly like Aman's is that Arpit got the drawings from Anupama's sketchbook. Anupama doesn't believe him and still believes that he is truly Aman. Anupama's best friend asks her to show proof. Anupama shows pictures of her and Aman at the movies when Arpit is still in America without even taking a second glance at the pictures. Her friend shows the pictures to her and she sees that Aman wasn't there. Later, it is revealed that she was the victim of schizophrenia and Aman was just a part of her imagination. Arpit and Anupama soon get married.

Autism Spectrum Disorder and Mental Health Comorbidity Leading to Prolonged Inpatient Admission.

Sam is a 6-year-old boy with a diagnosis of autism spectrum disorder (ASD) who recently relocated and has an appointment with you, his new pediatric clinician, to establish care. He was previously followed by a psychiatrist for 2 years for additional diagnoses of insomnia, bipolar disorder, anxiety, attention deficit hyperactivity disorder, and intellectual disability. He has tried and (apparently) failed multiple psychotropic trials including stimulants, nonstimulants, mood stabilizers, atypical antipsychotics, and nonbenzodiazepine hypnotics. He has a delayed sleep onset and frequent night awakenings each night for the past 3 months, during which he "screams, cries, and thrashes and can stay up for over an hour." His behaviors are described as irritable, self-injurious, and aggressive with no clear pattern of triggers according to his mother. He is nonverbal and communicates by leading and rarely pointing. The patient's current medication regimen includes clonidine 0.2 mg at night, lorazepam 1.5 mg as needed at night, olanzapine 5 mg twice daily, and diphenhydramine as needed for sleep/agitation. His mother is concerned that he is developing "tolerance" to the regimen and wants to wean him off some of the medications. His mother is struggling to take care of the patient given his worsening behavior and body habitus (body mass index >99%; z = 3.41).There is a family history of depression, anxiety, bipolar disorder, and autism. He has a 3-year-old sister, who is also diagnosed with ASD, though she is not as severely impacted. His mother's partner recently moved in along with 2 children of his own, aged 3 and 4 years. Sam attends a specialized school, where he receives behavior therapy and occupational therapy. He has undergone inpatient pediatric hospitalization twice, 1 time for 3 weeks and the other for 6 days, for aggressive behavior, and in both instances, he was discharged before inpatient psychiatric placement because of a lack of available beds.After urgent consultation with your local developmental and behavioral pediatrician, a slight reduction was made in the lorazepam because of concerns about tolerance and side effects. However, within a week of this, he was brought to the emergency department for continued self-injurious behavior and increased trouble with sleeping. His mother voiced concerns about his safety in the home, which were particularly related to aggression toward his younger sister. He was admitted to the pediatric inpatient floor for observation, and medication adjustment (increasing olanzapine), which was initially helpful in improving behavior, but mostly behavioral/environmental strategies were used to soothe him, including frequent wagon rides through the hospital corridors.Despite the patient being stable from the medical standpoint, Sam's mother did not feel comfortable taking him home. Social work contacted local community mental health services to pursue outpatient resources and respite care options and sought inpatient pediatric psychiatry. After several failed attempts to find placement, he remained in pediatric inpatient care for 1 and a half months with no acute medical interventions other than his oral medications.He was finally accepted to the in-state pediatric psychiatric facility when a bed was available. During his week-long stay, he had further medication adjustments with a decrease in olanzapine and optimization of his clonidine dose. During his psychiatric hospital stay, care coordination succeeded in arranging center-based applied behavior analysis interventions and respite care and parent training for his family. Sam began to show improvement in his overall agitation and aggression, requiring less clonazepam, and his mother then maintained outpatient follow-up.The day before discharge, you visit him in the hospital, and a medical student asks you why he was in the hospital for so long. How would you answer the question?

Perry Mason moment

Swingle researched the scientific literature on the subject as part of his extensive preparation for the cross. He found that the concept was both highly controversial within the psychiatric and psychological communities, and older than Dinwiddie claimed. At trial he got Dinwiddie to admit that she had only reviewed the victim's letters, had not been allowed to speak at length with any of her family members, and could not officially make a diagnosis as she was, unlike a psychiatrist, not a physician. Finally he asked if she agreed with a statement by Harvard Medical School psychiatry professor Harrison Pope that "it would be pure speculation for a psychiatrist to try to give a formal diagnosis of a dead person he has never met." She did agree, undermining her previous testimony. Seeing how effective that answer was, he ended the examination at that point. After a short redirect examination, she left the courtroom in tears. A cameraman for a local TV station called him "Perry Mason"

Parents seek early intervention services for a two-year-old without autism.

Sam is a 27-month-old boy who you have followed since birth. He lives with his parents in a small resort town approximately 90 miles outside a major city. Both his parents are professionals in their late 30s and have been highly involved in his care since birth. At the 12-month visit, they were concerned about his difficulty regulating. He was not sleeping through the night and had significant difficulty with baths. His physical examination and growth were normal. His eye contact was good, although it was difficult to see him smile. He had 1 or 2 words and was beginning to walk independently.At the 15-month checkup, they continued to be concerned about his poor regulation. He napped sporadically, and he was very difficult to take out on errands as he did not like his car seat. He now had approximately 10 single words, was using his fingers to point, and very clearly waved "bye bye" as soon as you entered the room.At the 18-month checkup, they state that he has not yet learned the word "no." He will follow a 1-step command when he wants to but now has 15 single words without any combinations. He points for his needs and to show them something. He has become increasingly "shy" around strangers and prefers to play with one other child as opposed to a larger group. He does not like loud noises and prefers to go barefoot constantly. His physical examination was again normal as was his growth. He is referred for a full hearing evaluation, which is also normal. The family was referred to early intervention, and he began receiving speech and language therapy and occupational therapy for his sensory challenges as well as a play group.At the 24-month checkup, his language continued to consist of single words-now approximately 30. When the parents do not understand what he wants, he will often tantrum and has started banging his head on the floor when frustrated. He has no repetitive behaviors and is starting to demonstrate imaginative play. Bath time has becoming increasingly challenging because he does not like the sensation of soap and the water temperature must be "just right." You refer the child to a Developmental and Behavioral Pediatrician for evaluation and at 28 months he is seen. During his testing visit, he had decreased eye contact and followed his own agenda but improved significantly as testing progressed. As he got more comfortable, he began making good eye contact, social referenced, and exhibited joint attention with his parents and the examiner. He did not meet criteria for an autism spectrum disorder or specifically pervasive developmental disorder-not otherwise specified (PDD-NOS). He was given a diagnosis of mixed receptive and expressive language delay and disruptive behavior disorder with sensory processing problems.The parents come to you a month after their evaluation visit asking you to give him a "listed diagnosis of PDD-NOS" that could be removed when he turns 3 years so that he may qualify for increased hours of services-up to 15 hours per week-as well as applied behavioral analysis therapy. A behavioral therapist through early intervention has told the family that he would benefit from this increased intervention, specifically applied behavioral analysis but the only way he can receive it is with a "medical diagnosis" on the autism spectrum. What do you do next?

Man of Many Many Faces

Man of Many Many Faces or The Man with Two Thousand Faces () is the sequel of Man of Many Faces. It is shown in Iran from March 21. Mehran Modiri is once again the director and main character for this TV show. It also starts: Pejman Bazeghi, Reza Feiz Noroozi, Siamak Ansari and Borzoo Arjmand.

The language and culture of delay.

Satish is a 3 (1/2)-year-old boy you are seeing in your primary care office for a "sick visit" due to parental concerns about his language development. He is the only child of a couple who immigrated to the United States from India shortly before his birth. He received early intervention services for speech and language delays for a few months before he attained 2 years of age. However, services were discontinued when the family moved back to India for a year. After the family returned to the United States, they lived in a different state for several months before moving again recently to his current home, so he is relatively new to your practice. Satish's mother is concerned not only about his communication skills but also about his attention and social skills. She notes that he often plays alone or in parallel with other children. She was also told by his first pediatrician that Satish had "a limited imagination." His parents feel that he has pretend play, in that he will pretend to get his haircut, talk on the phone, or ride on a train. Satish was born at term without complications. He passed his newborn hearing screen and a repeat hearing test at the age of 2 years. He has had no medical problems and takes a daily multivitamin. His parents are both of Indian descent. Satish's father is an engineer and had a history of being a late talker. His mother graduated from high school and is a homemaker. They are expecting their second child. Satish's developmental history is significant for language delays. He babbled at 6 months but did not have single words until he was 2 years. When he was 2 (1/2) years, he had 2 to 3 word sentences. He responded to his name at 15 months and could follow single step commands by the age of 2 years. Currently, Satish is noted to have difficulty with "back and forth conversation." He sometimes repeats what others are saying.The family speaks Hindi, their native language, exclusively at home. When Satish speaks, he usually speaks in Hindi. His parents describe him as using "odd language" in that he will often mix up his pronouns. Satish is in an English-speaking preschool. His preschool teachers report concerns that he seems to "withdraw into his own world," and does not interact well with the other children. They also report attentional problems and poor eye contact.In the office, Satish makes good eye contact with the examiner and his parents. He looks to his parents for approval when completing a task requested of him. He seems to like an Elmo toy that is in the room but holds it and looks at it closely rather than pretend to do anything with it. You ask him to feed Elmo, and he says, "Feed Elmo." Because it is not clear whether he understands the verbal cues given to him, his parents repeat English directions to him in Hindi several times. He eventually complies but then leaves his chair to explore the room. His parents continue to translate your questions to him with variable results. He becomes increasingly difficult to engage, despite repeated attempts, in both English and Hindi, to attract his attention. Where do you go from here?

Sorry, I've Got No Head

Introduced in Series 1 Headless Bill, a man with no head who gets into some sticky situations and who gives the show its name. Appears in series 1–2 but not in series 3. Jasmine and Prudith, who believe everything will cost a thousand pounds, despite what the person they're interacting with says. However, after they encounter the person they say that they will do something that would generally cost at least a thousand pounds, such as buying a mansion or a yacht. Appears in every series. The Fearsome Vikings who are scared of everything. Appears in every series. Emily and Monty Forrest, a brother and sister duo act who try to get a performance in a show, but fail at getting the part when a routine of theirs goes horribly wrong. In series 3, they try to make their own show. Appears in every series.

High-Functioning Autism, Severe Anxiety, and Bullying in a 26 Year Old.

Peter is a 26-year-old group home resident in Austria with a history of poor peer relationships, including being bullied, and previous diagnoses of attention-deficit hyperactivity disorder, Asperger syndrome, social anxiety, depression, and developmental coordination disorder. Consultation from our international neurodevelopmental team was requested for severe anxiety and avoidance of social interactions. He reported 4 or more spontaneous anxiety episodes per day. Anxiety triggers included returning to his group home from his vocational rehabilitation program each evening or returning to the group home after weekends at his parents' house. Each Sunday evening, in anticipation of returning to the group home, Peter engaged in tantrums, including screaming and throwing objects and suicidal threats without intent, but not direct aggression toward family members. He phoned his mother several times per day on weekdays.Peter's early history was significant for hyperactivity, impulsivity, aggression, and socially intrusive behavior; he repeated kindergarten and by first grade was characterized as motorically clumsy and "too much in [peers'] personal space." He played alone in kindergarten and had poor social boundaries; when older, he evidenced reduced social perception, and his family reported he did not notice when peers made fun of him. His language developed normally, but he had a "sophisticated style of speaking" and as an adult continued to have trouble understanding gestures, jokes, and social themes in movies.Between ages 7 and 11 years, Peter had been bullied and ostracized by male peers but did well academically, always got along well with adults, and preferred to play with girls. Exclusion by peers persisted through high school, at which time his independent functioning declined and he required his mother's assistance with organizing his materials. At age 15 years, Peter repeated a grade so that he could change classmates, and by the equivalent of his junior year, his grades deteriorated. He had several psychiatric admissions for depression and destructive outbursts (to avoid going to school) and was diagnosed with Asperger disorder. At age 18 years, Peter refused to return to school. He lived at home with his parents, only leaving the house to accompany them on errands, until placed in a group home for people with mental health disorders at age 20 years. At age 26 years, he is sharing a supported-living apartment with 2 young adults with chronic psychiatric disorders. He works in 3 highly structured sheltered workshops for a few hours each and becomes easily overwhelmed in unstructured situations and/or in situations in which he anticipates being reprimanded or letting someone down. Despite a strong interest in marine biology, anxiety prevents him from considering college.How would you proceed with diagnostic testing or intervention to help this young man?

Bénédict Morel

In 1857, Morel published his degeneration theory in Traité des dégénérescences physiques, intellectuelles et morales de l'espèce humaine et des causes qui produisent ces variétés maladives. In his work, he included images of twelve patients that demonstrated the physical, mental, and moral traits that were evidence of degeneration. Some of these characteristics included altered ear shape, asymmetrical faces, extra digits, and high-domed palates that had psychological representations as well. Morel's work was well received. It connected psychiatric medicine to general medicine to provide a complete and well-researched cause for a large social problem. It became dominant because it grounded moral treatment, which was questionable in this time period, in science. Morel's theory also allowed psychiatrists who were unable to help their patients explain why they had not been successful. Degeneration theory meant that there were some psychological disorders that were genetic and could not

Toddler Sleep Challenges: All in a Day's Work.

Leo is a 26-month-old boy who you are seeing for an urgent care visit due to "sleep difficulty," particularly sleep onset. Since age 1, he screams, hits, and kicks his mother every day, starting after she gets home from work at 5 PM (or before the family's dinnertime on her days off) and escalating over the course of the evening until he "wears himself out" and falls asleep in a crib in his own room around 9 to 10 PM Once asleep, he sleeps well through the night and wakes easily around 7 AM in a pleasant mood; his mother leaves for work soon after he awakens. He naps after lunch for 2 to 3 hours on weekdays at an in-home child care with 1 to 2 adult caregivers and 5 other children aged 0 to 5 years. He refuses to nap at home.Leo goes to bed easily when his father puts him to bed if his mother is not at home, but his mother feels that evenings are the only time she can spend with Leo, and so, she tries to put him to bed most nights. However, because of Leo's behaviors at bedtime with her, she feels inadequate, depressed, and guilty; when she tries to disengage or allow her husband to help, Leo screams, "Mommy, mommy!" and tries to gain access to her and resists his father putting him to bed until his mother returns. Both parents worry that "he would not grow out of this," and his mother now avoids coming home from work for fear of Leo's behavior. Both parents feel that this situation is causing marital strain.Leo was born healthy at full-term and is an only child; pregnancy was complicated by hyperemesis gravidarum. Leo has been healthy and meeting developmental milestones. His parents describe his temperament as "like his father at that age," "easy, but never able to self-soothe," "intense" in his emotional reactions, persistent, "strong-willed and serious," and "shy and observant, withdrawn at first and then getting more pleasant after a while" in novel situations. Behaviorally, he engaged in noninjurious head-banging at home when upset between 12 and 15 months; bit children a few times at child care between 20 and 24 months; and lately refuses to share or will push other children at child care every few weeks. His parents recently read a book about parenting "spirited" children but did not find it helpful. What would you do next?

The Man Who Had No Idea

"The Man Who Had No Idea" is a 1978 science fiction story by Thomas M. Disch. It was first published in The Magazine of Fantasy and Science Fiction. Plot summary In a world where licenses are required in order to participate in conversation, Barry Riordan risks failing his exam because he cannot think of anything original. Reception "The Man Who Had No Idea" was a finalist for the 1979 Hugo Award for Best Novelette John Sladek considered it to depict "delightful problems". Kirkus Reviews noted that it "say(s) a great deal about our expectations of ourselves and others." John Clute, however, found it to be "unaccountably genial and without formal bite", such that its "potentially formidable idea gradually declines into doodle". Origins

Scott: an 11-year-old boy with repetitive lying.

Scott, an 11-year-old boy in the fifth grade, is brought to his pediatrician, Dr. Lewis, by his maternal grandparents with the principle concern that "he lies constantly." Scott lived with his maternal grandparents since he was 2 years old, and they have full custody. His mother and father had serious substance abuse problems. The grandparents provide a stable home for Scott and his 15-year-old sister. Scott has had no contact with his mother in more than 6 years and sees his father infrequently. During the last visit with his father, he was so inebriated that he was thrown out of the movie theatre and barely avoided several car accidents on the way home. He left the children at the curb of their home and made them promise that they would lie to their grandparents about the reasons for the early return. Scott was diagnosed with attention-deficit hyperactivity disorder (ADHD) in second grade. Methylphenidate (36 mg) provides improvement in attention and concentration. His grandfather describes Scott as highly unpredictable. When he is the "good Jake," he is eager to help, polite, and caring. When Scott gets behind in school or is avoiding his chores and assignments, he lies by saying that he got it all done, even though he knows his grandfather will discover the lie and punish him. When confronted with reports from school, Scott often lies and may develop more elaborate confabulatory stories. His grandfather admits that he becomes irate at these moments. He responds by removing Scott's privileges. When he planned to take Scott to see his favorite sport team in the playoffs, Scott was caught in a lie the day of his departure. His grandfather offered him a chance to fess up, pay a small price in extra chores, and save the trip. Scott stubbornly refused to admit that he lied and lost the trip. His grandfather worries that Scott has no "moral compass." He takes things that do not belong to him and violates household curfew rules. He has never been physically aggressive or has never stole items from a store. He takes his sister's CD player or his grandfather's cell phone even when he has been told not to. He will then lie that he did not take it. Even when it is pulled out of his backpack, he will say he did not put it in there. His grandfather is a businessman with high moral integrity. He loves his grandson and is eager to help him. He asks Dr. Lewis what they should do about Scott's persistent lying.

The Amazing Maleeni

The show centers on FBI special agents Fox Mulder (David Duchovny) and Dana Scully (Gillian Anderson) who work on cases linked to the paranormal, called X-Files. Mulder is a believer in the paranormal, while the skeptical Scully has been assigned to debunk his work. In this episode, The Amazing Maleeni, a small-time magician, performs an amazing feat to impress a heckler—he turns his head 360 degrees. So when he is later found without a head at all, Mulder and Scully arrive on the case and discover an angry ex-con, an unimpressed rival, and Maleeni’s twin brother. All seem to have something to do with a plan to rob a major bank.

Features of Catatonia in a 12-Year-Old Boy with Autism Spectrum Disorder.

Thomas is a 12-year-old boy with autism spectrum disorder who presents to his primary care clinician with symptoms of worsening mood in the last 3 months. On review of his last school testing, his cognitive abilities are found to be within the average range, with a relative vulnerability with his processing speed. He can speak in sentences to communicate and answer questions, but he rarely picks up on conversational bids. He has had difficulties developing friendships and often prefers to play by himself.Thomas has a long history of some features of anxiety and depression for which it was recommended that he establish care with a therapist, but his family has had a hard time finding a provider for him. At this visit, the mother reports that for the past several months he has been more anxious, sad, and easily overwhelmed. He seems irritable at home and school and cries often. His family has been advocating for him to receive increased school supports, as school is a source of anxiety for him, but there are no recent changes in school services. There is a family history of both anxiety and depression. Given his worsening mood functioning, Thomas was started on selective serotonin reuptake inhibitor (SSRI) medication in addition to again recommending a therapist. Weekly phone call check-ins and an in-person clinic visit in 1 month are planned.About 1 month after starting the SSRI medication, he is still not showing any improvement in mood functioning, and his family reports he seems more "sluggish" than usual. There are no side effects reported with the medication, and the dose is increased to see whether it will help. However, about 2 weeks later, he is seen again in the clinic because there are increasing concerns. He continues to be "sluggish." During the clinic visit, he lies down on the examination table, sometimes holding his head off the edge of the table, which he has never done before. He responds very slowly to the questions and often says "I don't know, I don't know," almost in an automatic way. His mother reports that he is now engaging in some repetitive hand movements which he had not done previously. He is no longer able to shower independently. He is still eating and drinking adequately. What would you do next?

The Man Who Saw Tomorrow

Welles himself completely rejected the central theme of the film after having made it. It is not known if Welles was contractually obligated to narrate the film, or if he simply grew disenchanted with its subject matter and presentation after completing it. Perhaps Welles' most public criticism of the subject matter of the film occurred during a guest appearance on an early 1980s episode of The Merv Griffin Show; "One might as well make predictions based on random passages from the phone book", he offered when asked about the film, before moving on to discuss other projects more interesting to him personally. Alleged predictions of Nostradamus in The Man Who Saw Tomorrow

Care under the Influence.

A forty-year-old man is brought to the emergency room by his wife at five in the morning, two hours after he fell down the stairs at home, hitting his head and injuring his arm. He tells the ER physician that he got up to get a drink of water and tripped in the dark. His speech is slurred, and he smells strongly of alcohol. Lab results reveal elevated liver enzymes, and his blood alcohol level is 0.1. His medical history is unremarkable. When asked about his alcohol consumption, he says he usually has one or two drinks a night with dinner but that he drinks more on holidays and special occasions. He admits he had more to drink than usual last night because it had been a stressful day at work, but he is vague about how much he drank. His wife takes the ER physician aside and describes a very different situation. She says that her husband regularly has three or four drinks a night. She always goes to bed before he does and thinks he stays up later so he can continue to drink. She says that he often has no memory of conversations they had the night before and is concerned because he makes work-related calls at night. When asked what he does for a living, she hesitates, and then answers that he is an internist. He does not work at this hospital but works at one of its affiliated clinics. The ER doctor is concerned that his patient is an impaired physician. Yet when the admitting hospitalist, to whom he explains the situation, asks if he really wants to "go there," he shrugs his shoulders. "I suppose," she replies, "you might as well call an ethics consult."

Meredith Grey

Rhimes felt that the 100th episode showed well Meredith's evolution throughout the show from a "dark and twisty girl" to a "happy woman". She said: "She is the thing her mother wished for her. She is extraordinary. Because, to get past the crap of your past? To move on? To let the past go and change? That is extraordinary. To love? Without fear? Without screwing it up? That is extraordinary. It makes me happy to see her happy." Following the departure of Patrick Dempsey's character, Rhimes was quoted as saying that "... Meredith and the entire Grey's Anatomy family are about to enter uncharted territory as we head into this new chapter of her life. The possibilities for what may come are endless." With at least a year left in Pompeo's contract with the show, viewers are sure to witness some of the most difficult times of Meredith's life yet. Reception Reviews

The Case.

Mr. Hope is a 40-year-old man who has resided at a long-term care facility for the past 10 years. The resident was originally admitted to the nursing home for his inability to care for himself secondary to advanced AIDS and complications from progressive multifocal leukoencephalopathy (PML). When he initially arrived at the nursing home, Mr. Hope was able to smile and appeared to respond to some of the staff's requests. Now, he responds by wincing when told that procedures are being performed and especially when he is told that he has to go back to the hospital. He is extremely contracted, with his arms wedded to his chest in a crossed fashion, as though he is protecting himself from blows. Mr. Hope's family consists of a partner, his parents, and one sibling. Numerous conversations have been had with the family, and according to the facility staff, "they persist in continuing aggressive measures with the hope that the patient will wake up and walk out of the facility." What had been frequent visits to the local hospital ER have increased substantially in the last few months, for what appear to be new infections and pneumonia. During most visits he ultimately spends a few days in the hospital to resolve his acute issues. On his most recent return to the long-term care facility, the medical staff approached the family about Mr. Hope's code status. The family continues to insist on a full code status and that he be provided every opportunity to "live." The staff is very concerned about Mr. Hope and his welfare. Many of the nursing staff have grown attached to him over the years, and watching him deteriorate has been distressing. They see part of their role as being his advocate and supporting him in ways that his own family has not. They express very strong reservations about performing CPR on Mr. Hope because they think it will be ineffective and they will have to break his upper extremities in order to gain access to his chest for resuscitation. The staff has contacted the ethics consultation service with the request that Mr. Hope needs protection and that his own family is not making the best decisions for him.

I Wanna Get Better

The video depicts a day in the life of a therapist (Antonoff) who, after getting dumped by his girlfriend (Kimiko Glenn), proceeds to his office and meets a variety of clients, all of whom are depicted describing their own personal problems. Comedian Retta and actor Mike Doyle play a couple who are suffering from marital problems while actor Rizwan Manji plays a highly-strung patient who gets distracted by "Bring Your Daughter To Work" Day. Actress Mary Kay Place plays a patient who is accused of creating "drama" because she thinks her husband is having an affair and the therapist does not believe her. Musician Arrow De Wilde appears in the video as a sullen, disaffected teen. Throughout the video, the cast are filmed lip-synching to the song's lyrics and sometimes even playing instruments as the band members.

Bullying and ADHD: Which Came First and Does it Matter?

Aiden, a 13-year-old boy in the sixth grade who is relatively new to your practice, is seen for follow-up after his routine physical last month when you noted concerns for possible attention-deficit hyperactivity disorder (ADHD) and gave the family Vanderbilt Scales to complete. Aiden has a family history of ADHD, specific learning disabilities, and mood disorder.His mother reports that she is concerned about how Aiden is doing at school; his teachers are complaining that he is not doing his work, and she is worried that he may be kept back in school. Aiden first began having trouble in the third grade. He was retained in the fourth grade for academic and behavioral reasons. Now his mother has been receiving calls about him not paying attention, distracting others, and staring at his paper. At home, he does not want to do homework and gets very frustrated. In fifth grade, he had a psychoeducational evaluation and was found not eligible for services. His achievement testing showed average scores in reading, math, and writing. Cognitive testing demonstrated average scores for verbal and nonverbal abilities and memory but was significantly below average for processing speed. Aiden continues to have problems now in into the sixth grade.You speak with Aiden in the office and ask him about school. He says, "It's bad. I'm failing." He believes his major problems at school are that he is not doing his homework, he easily becomes frustrated, and he argues with the teachers. He has supportive relationships with his family and friends at school. He gets along well with some of his teachers, noting that he loves his science teacher even though she is tough and "gives hard homework." He describes his history teacher as "annoying." When you ask what he means he states this teacher "Can be not nice and says mean things. She picks on me a lot." His description is consistent with the use of shaming as a behavior he experiences at school.You review the completed parent and teacher Vanderbilt forms; both are consistent and concerning for combined type ADHD. You discuss the diagnosis of ADHD with his mother and both agree to revisit pharmacotherapy in September when the school year resumes. You give her resources on ADHD and classroom accommodations and discuss requesting a 504 plan at school. You also discuss behavioral therapy to better address his self-regulation skills.A week later, you receive a telephone call from Aiden's mother. "Aiden got home today and he is more upset than I have ever seen him! His teacher told him in front of the class that he would probably stay back a year and now he is saying there is no point in going to school." She is not aware if retention has been recommended for Aiden.What would you say to Aiden's mother? What would you do next?

The Doctor's Wife

The move to the sixth series also meant Gaiman had to include Rory, who had ceased to exist in the original slot in the fifth series. With Rory included, Gaiman had to "reshape" much of the second half of the episode, featuring Amy being on the run in the TARDIS. In the original draft where Amy was the only companion, Gaiman added a "heartbreaking monologue" by the character, further stating "you get to see what it's like to be the companion from the companion's point of view, and she got to talk about essentially in that version how sad it is, in some ways. One day something will happen to her, she'll get married, she'll get eaten by monsters, she'll die, she'll get sick of this, but he'll go on forever." At a certain point, Gaiman became tired of rewriting drafts and asked Steven Moffat for help. Moffat wrote in what Gaiman called "several of [the episode's] best lines" and rapidly rewrote several scenes when budget problems harmed filming locations.

Bullying and ADHD: which came first and does it matter?

Jalebi (film)

Unfortunately, Aisha has a miscarriage and Dev's mother blames Aisha for it. Aisha feels humiliated and insulted and leaves Dev. A few days later, Dev and his family try to bring her back but she doesn't return. She calls Dev to meet her in Kashmir if he really loves her, but Dev does not come. Seven years later, Aisha calls off her second wedding as she is still in love with Dev. She decides to face her problems and travels to Delhi. On her way, she meets a woman named Anu and her daughter, Pulti, and discovers that Anu is Dev's second wife. She also meets Dev in the same train. During the journey, she reminisces about her marriage with him. She also finds out that Pulti's original name was Disha, and feels upset, chiding Dev for naming her that. Anu also reveals that Pulti was not Dev's child but Anu and her lover's. Dev lifted at the very next moment he saw Pulti and before marriage he had a single condition that she should be named Disha.

"Media addiction" in a 10-year-old boy.

Bryan is a 10-year-old boy who is brought to his pediatrician by his parents with concerns about oppositional behaviors. Bryan's parents report that he has always been hyperactive and oppositional since a very young age. He has been previously diagnosed with attention-deficit hyperactivity disorder and has been treated with appropriate stimulant medications for several years; however, despite this, his parents feel increasingly unable to manage his difficult behaviors. He refuses to do chores or follow through with household routines. He refuses to go to bed at night. His family feels unable to take him to public places because he "climbs all over everything." At school, he acts up in class, is often disruptive, and requires close supervision by teachers. He was recently kicked off of the school bus. He has very few friends, and his parents state that other children do not enjoy to be around him. Bryan's parents also report that he is "obsessed" with electronics. He spends most his free time watching TV and movies and playing computer games. He has a television in his bedroom because otherwise he "monopolizes" the family television. The family also owns several portable electronic devices that he frequently uses. Bryan insists on watching TV during meals and even that the TV stays on in an adjacent room while showering. He gets up early each morning and turns on the television. He refuses to leave the house unless he can take a portable screen device with him. His parents admit to difficulty placing limits on this behavior because they feel it is the only way to keep his other behaviors under control. His mother explains "it is our only pacifier" and that attempts to place restrictions are met with explosive tantrums and have thus been short lived. These efforts have also been impeded due to the habits of his parents and older sibling, who also enjoy spending a significant amount of time watching television.

Last Remains

best for everyone, and that his hubris causes his loved ones to either get hurt or die. But instead of Peter accepting his mistakes, he chose to bury them or ignore them, like what he did to Norman Osborn in "Sins Rising". Harry is also disgusted that Peter tried to bargain and make the deal with him while also not revealing the truth to his allies like Doctor Strange. Peter sees Sin-Eater shooting Morlun, and also sees Sin-Eater waiting for the spider-heroes. A frantic Peter brings up their deal, to which Kindred notes that he had kept his end of the deal, that their arrival was an unintended consequence of Peter's actions and thus doesn't absolve him. Since they came for Peter, Kindred asks his confused old friend what else he did to bring unintended suffering onto others. Kindred urges the begging Peter to answer quickly, presenting on a large mirror display that Mary Jane Watson is entering his cemetery.

Discovering gifted children in pediatric practice.

Casey is a first grader who is brought to the pediatrician for consideration of ADHD. His mother is concerned that he is very difficult to focus at home when asked to do anything and gets so distracted at meals that he eats very little. The teachers last year and this year say that Casey is very distracted, always "in a fog" and just can't seem to get his work done. "He's in his own world." His report card has several unsatisfactory marks because of poor completion of work, doing things other than the assignment and talking too much to the kids around him. The parents are very upset as they see their son as very bright. His advanced vocabulary, early reading skills and his extensive knowledge of engines, machines and aircraft were all noted in his medical chart in the past as part of his health supervision visits. He has lots of friends, mostly third graders and plays soccer with moderate success. The paternal grandmother says Casey is just like his dad who is now a biochemical geneticist. He too had a hard time getting his work in as a child and "always talked back" to the teacher. Casey's mother would like him on medication before the Iowa Basics come around. The Vanderbilt rating scales by both teacher and parent are positive for inattention and borderline for hyperactivity. Casey took it upon himself to speak to the principal about how bored he was with the classroom work. She agreed that he could have some special assignments. In the pediatrician's office, Casey is a delightful, verbal, thin boy who has about 100 things to talk about, from train engines to the sports scores, acquired from the television sports channel, to what should be done to "fix" his school. He said he was bored and knew more about volcanoes than the science teacher. He just wanted to get home each day and work on his elaborate train setup. He doesn't seem overly active, distractible, anxious, inattentive or oppositional. Testing by the school psychologist showed him to have an IQ of 138 with an even verbal/performance profile. Sam is a 4-year old whose parents brought him to the local private school for application to kindergarten. The admission requirements consisted of a group "developmental" test, given to groups of 20 youngsters at a time. Sam failed the test. The report said that he was too immature, talked out of turn and generally wasn't ready for the vigorous academic program planned at that school. He asked too many questions and argued with the admissions person. They suggested he might need medication before he attempted school. His parents asked their pediatrician for an opinion on the school report. They asked for a referral for testing as they could not believe their son was a preschool failure. The psychologist reported that his IQ was 142 (verbal 146 and performance 136).

Assyrian law

"If a man catch a man with his wife, both of them shall they put to death. If the husband of the woman put his wife to death, he shall also put the man to death. If he cut off the nose of his wife, he shall turn the man into a eunuch, and they shall disfigure the whole of his face." "If a man have relations with the wife of a man at her wish, there is no penalty for that man. The man shall lay upon the woman, his wife, the penalty he wishes." "If a man say to his companion, "They have had intercourse with they wife; I will prove it," and he be not able to prove it, and do not prove it, on that man they shall inflict forty blows, a month of days he shall perform the king's work, they shall mutilate him, and one talent of lead he shall pay." "If a man have intercourse with his brother-in-arms, they shall turn him into a eunuch."

Attention deficit hyperactivity, fetal alcohol spectrum disorder, or something else: the broad differential of kindergarten suspension.

Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating "and his doctor must see him before he can come back." His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds. The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as "hyperactive" by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom. His parents have always described him as a "difficult child." He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited. Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed "partying" with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant. All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?

List of Keeping Up Appearances characters

Those around her despise her snobbery, her constant meddling, her outlandish plans and her refusal to listen to others. Hyacinth seems completely oblivious of everyone's terror of her and wants to believe the best of most people, that they are either enamoured with her and too shy to say so or that they are trying to be considerate of her by not bothering her. However, she cannot abide anyone one-upping her when it comes to social events or showing the same snobbery she herself shows. She has a penchant for finding the most disagreeable people to try to impress, while at the same time shunning agreeable people who are of lower social standing, but never seems to learn from her mistakes.

Norman Osborn

Norman Osborn is shown to be severely manic depressive. This has been referenced several times in a myriad of Spider-Man stories. When he is not under the direction of a psychiatrist and taking medication, he has dangerous mood swings. At the apex of his mania, he is paranoid, delusional, and suffers from visual and auditory hallucinations, including hearing the voice of his Green Goblin persona and seeing its face in the mirror rather than his own. Previously, Osborn's arrogance caused him to refuse to submit to psychiatric treatment unless forced to; he viewed mental illness as an imperfection and therefore would not admit that he is mentally ill. In later conversations with the Sentry, Osborn revealed that he had come to accept his own mental illness. After having rid of his powers after the confrontation with the Superior Spider-Man (Doctor Octopus), Osborn's sanity apparently restored but remains a villain.

Electrocardiogram before starting stimulant medications: to order or not?

D is an 8-year-old boy brought to his paediatrician for evaluation. His mother is concerned as his teacher has been frequently complaining that he is very restless and often disturbs the rest of the class by getting up on some pretext or the other. He is unable to concentrate on his work and gets distracted very easily. He makes many careless mistakes and can hardly finish his tasks on time. He is frequently reprimanded for talking during class. He often answers out of turn or before the question has been completed; however, so far, he has been managing to get passing grades. At home, he is constantly on the go while he is awake. If he is forced to sit, like at mealtimes, he fidgets a lot. He also needs to be constantly nagged to do everything, even his daily activities such as brushing his teeth, or he forgets to do them or leaves them incomplete. He takes ages to finish his food. It is a major job to get him to do his homework. His mother says that at home he has been like that since the last 2 to 3 years, but now she is concerned because of the difficulties he is experiencing at school as well. After obtaining his medical history, examination, and getting response from parents and teachers--using Vanderbuilt Assessment Scales--the paediatrician diagnoses him to have attention deficit hyperactivity disorder. Besides behavioural interventions, he considers medications for his management. The paediatrician is debating the merits of performing electrocardiogram and/or referring the boy to a cardiologist before starting stimulant medications. If you were caring for this patient, how would you proceed?