睿学教育Wisdome Education

Heather Teufel, PharmD, BCPS

• Clinical Pharmacist
• Emergency Medicine, University of Pennsylvania Health System�Chester County Hospital, West Chester, Pennsylvania

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This work was dedicated to his father and work in the sermon that he delivered at the funeral to Richard Morton bipolar depression forums generic 20 mg abilify visa. Baglivi depression symptoms feeling sick order abilify in india, Havers received the distinction of being elected a when he stood for Anatomy Professor in the Fellow of the Royal Society and he was admitted Sapienza at Rome anxiety supplements abilify 15 mg online, took his Lecture. Constituent Parts, and Internal Structure of the Hands being put in nomination for reading of the Bones”; October 30 and November 13, 1689, same. Havers was chosen for three years to “The second Discourse of Accretion and Nutri- read on the second Tuesday, Wednesday and tion”; January 29, 1689, “The third Discourse of Thursday in July next by three of the clock in the the Marrow”; November 20 and 27, 1689, “The afternoon and to have thirty shillings for his pains fourth Discourse of the Mucilaginous Glands”; and the remainder to be disposed of by the Com- August 13, 1690, “The fifth Discourse of the Car- mitte. John Gale, who left an annuity of book in 1691, under the title Osteologia nova, or £16 to the Company of Barbers and Surgeons for some Few Observations of the Bones, and the this purpose, and as the records do not show the Parts belonging to them, with the manner of their appointment of any previous lecturer, Dr. The records do Richard Morton, in which he makes the follow- not reveal how they disposed of the rest of the 131 Who’s Who in Orthopedics money. Tyson” (who from the register in Willingale Church, the writer had recently retired). Howell: “Clopton Havers, MD, was buried April This is entitled “A short Discourse concerning 29th, 1702, in what was made of sheep’s wool Concoction” and it appeared in the Philosophical only and affidavit thereof made and delivered the Transactions of the Royal Society in 1699 (vol. Possibly too much of his time accordance with a law passed in 1666 in the inter- was occupied in the exercise of his profession to ests of the wool trade, and the following is an permit any further great literary efforts after the extract from the Act: writing of his book in 1691, but certainly no facts are available to fill in the gap between this date For the encouragement of the woollen manufacture of and 1698. In 1702 was published a new edition of the kingdom, no person shall bee buried in anny shirt, Spaher and Remmelin’s, A Survey of the Micro- shrewd or sheet made of wool mingled with flax, hemp, cosme, or the Anatomy of the Bodies of Man and silk, hairs, gold or silver or any other than what shall Woman, edited and corrected by Havers. This be made of wool only or be putt into anny coffin lined must have been his last work, for in April 1702 or faced with anything made or mingled with flax, hemp etc. He was buried at Willingdale Doe in parish when such person shall be buried. Essex, in the grave of Thomas Fuller, a former rector of the parish, whose daughter he married. From In the same grave are the bodies of six of his chil- the same parish records comes the information dren, none of whom lived more than 3 years. The that Mary, the daughter of Dorcas Havers, the following extracts from Lilly Butler’s funeral widow, was buried at the same church on May 6, sermon give some estimation of his character: 1702, only a week after her father’s interment. He was a most respectful, dutiful son to his aged Father, Another entry records the burial of a Clopton frequent and liberal in making his acknowledgments to Havers, presumably the doctor’s son, on Novem- him for his ingenuous and chargeable Education, and ber 7, 1709. Having engaged himself in an honourable and Improvement in this last Age than Physick, so no part useful Calling, he faithfully pursued the Designs of it, of that has been more tempting, or more successfully as one who remembered the account he must give to pursued than Anatomy. The Dissections of many pre- the Maker of those Bodies he had undertaken the care ceding Ages turn’d to a small account; so that many of of, and truly Watched for their Lives. He took a great the most admirable Contrivances of Nature and of the deal of Pains to improve himself in that Knowledge greatest Wonders in the lesser World, were inobserv’d; which was necessary to qualify him for a laudable till the Curiosity of some ingenious Men, animated discharge of so great a Trust.... His Countenance with the hopes of some new Discoveries, put them upon was grave and serious, without any lines of Sorrowness farther Enquiries; in which their Industry and Felicity or Affectation; his Speech was soft and obliging, carried them so far, that the Existence of some parts without any Air of conceit or Flattery; his Behaviour before unknown, the Nature, Structure and Use of gentile and courteous, without any Appearance of Art others, began to appear. Observations of our Age about some of the Parts have been very accurate, we have been only coasting about Dr. Luke and said that others; particularly about the internal Fabrick, and “he was not only esteemed by his Patients for his some other things of the Bones our Searchers have been great abilities and care and diligence, but exceed- careless, our Notice slight and transient: not but that ingly beloved too for his amiable Temper, his they deserve our strictest Enquiry and serious Remarks; obliging Tenderness and his most winning and for I do not see but the Almighty Architect has equally excellent Virtues. And how curious the Hand of his ingenious theory that the “porosity” decreased Heaven has been in the Framing and Ordering of this from the cavity towards the outside of the bone Timber-work of our Bodies, may perhaps appear a little because the amount of lubricating medullary oil from this Discourse. It seems very likely that Anthony van The particular concern of the present paper is to Leeuwenhoek, the pioneer microscopist, had give the original description of the “canals,” already observed these “canals” in bone, for in his which is to be found on page 43 of the English letter published in the Philosophical Transactions editions and on page 47 of the Latin edition pub- of the Royal Society on September 21, 1674, he lished in Amsterdam in 1731: makes the following statement: “I have several times endeavoured to observe the parts of a Bone, In the Bones, thro’ and between the Plates, are formed and at first I imagin’d, I saw on the surface of the Pores, besides those which are made for the Passage of Shinbone of a Cow several small veins (which the Blood-Vessels, which are of two sorts; some pene- bone I still keep by me); but I have not found trate the Laminae, and are transverse, looking from the it since in any other bone”... And that I may not be thought to pretend makes no other comment on this observation and to the discovery of what no other mens Eyes can so it must remain doubtful whether the structures discern, because they are generally very difficult to be he saw were actually those that later became observ’d, unless it be the transverse Pores in the inter- nal Lamell, I have the pieces of two Bones, which I known as Haversian canals. Havers was no copyist and he rightly not arranged in any kind of pattern, but have a named his work as Osteologia nova. That his “seeming irregularity,” which tends to preserve canals contained blood vessels and not merely the necessary strength of the bone tissue. The lon- medullary oil as he contended and that they had gitudinal pores are more difficult to see, but are probably been known previously to Leeuwenhoek best observed in the ribs. Havers assumed that the does not detract from the merits or the originality use of these pores was solely for the diffusion of of his observations at a time when the dissemina- the “Medullary Oil” for, he says: “About these tion of scientific knowledge was of necessity passages I was particularly strict in my enquiry, restricted.

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Record any unusual or potentially dangerous events (Pagano and Ragan 1992) molal depression constant definition discount abilify uk, for example a fall or self-harming anxiety burning sensation effective 20 mg abilify. There are usually stand­ ardised depression symptoms on the body abilify 20 mg order fast delivery, pre-prepared incident forms designed specifically for this purpose. Note your observations of the client’s general condition Record any change in symptoms and your actions in response to this. Note the comments of the client and his or her significant others Make a note of any discussions with the client and family about progress, intervention and the health problem. A summary is often useful when the notes are lengthy or there are sev­ eral entries during a shift. This enables other staff to quickly assess the cur­ rent status of the client. Evaluation Although evaluation must be an on-going process throughout interven­ tion, each careplan must also include a review date. This will be the date when you expect the client to have achieved the goals set in his or her careplan. Checking whether the planned outcomes were achieved or not is one way of judging the effectiveness of your intervention. Good practice emphasises the involvement of the client and his or her sig­ nificant others in evaluating outcomes. Evaluation completes the three parts of the intervention stage: ° planning the careplan ° implementing the careplan ° evaluating the careplan. A complete record at the intervention stage of the care process will show: ° the client’s consent to treatment ° how your intervention was planned ° the actions you have taken to meet the needs of the client ° the reasons or rationale for your actions ° the reasons why any planned actions did not take place ° the client’s progress in relation to the stated goals of intervention ° the quantity and quality of the care you have delivered ° that you have fulfilled your duty of care. Key documents to be kept on file: q careplan(s) q consent forms for treatment, therapy or surgery RECORD KEEPING 65 q progress records q incident forms. Discharge Discharge signals the end of the client’s episode or episodes of care. The information you record in the notes at this final stage will help to demon­ strate the rationale underpinning your decision to close the case. This would include: ° the results of any assessments, tests or investigations ° the client’s progress in relation to the stated goals of intervention ° the client’s ability to manage his or her on-going care needs ° the wishes, views and opinions of the client, his or her family and any other significant person. Your clinical judgement to discharge will be based on all of the above in­ formation. Your notes are also important evidence that the discharge was planned, and that steps were taken to ensure continuity of care for the client. Record the actions you have taken in preparing the client for discharge. This might in­ clude: ° enquiries to other agencies regarding support for the client on discharge ° informing relevant agencies regarding the client’s on-going needs 66 WRITING SKILLS IN PRACTICE ° making referrals to other services ° discussions with the client, family and carers. The referrer, general practitioner and any other key agencies involved with the client will need to know that your involvement is now completed. In cases where the client has died, the clinician may also have personal re­ sponsibility to notify colleagues of the death. Part of discharge will be helping the client and his or her family un­ derstand when and at what point your responsibility ends (NHS Training Division 1994). Risk increases if the client is not fully informed, as confu­ sions may arise if further support is needed in the future. The client needs to know: ° the professional or service responsible for any on-going health needs ° the circumstances that would initiate a re-referral to your service ° the route for such a re-referral. Make a record of not only what discharge information was given to the cli­ ent but also the views of the client and his or her family about the decision to discharge. Clients may require directions about medication, self-administered health care or therapy regimes for use post-discharge. This decreases the chance of error, and reduces the record keeping load as copies of the information can be easily filed in the notes. A med­ ication instruction sheet would have the following: ° client identification data ° name of the medication ° dosage ° when to take it ° how often to take it ° how to take it (for example after a meal with water) ° date of the instruction ° signature (and name in full) with position of prescriber.

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The usual protocol papa roach anxiety abilify 20 mg otc, derived from experience with adults bipolar depression blogs discount 15 mg abilify fast delivery, involves exchanges on the 1st anxiety thesaurus abilify 20 mg order on-line, 3rd, 5th, and 7th days targeting a total exchange volume of 250 mL=kg. Problems with plasma exchange include difficulty with placement and maintenance of central lines and hypotension during exchanges. If patients experience a relapse within approximately 10 days of the first treatment, retreatment with the same initial agent at half the dose is recommended. Prognosis Overall prognosis in GBS is good with approximately 90–95% of affected children making a complete functional recovery within 6–12 months. Those who do not recover completely are often ambulating independently with only minor neurologic residua. Since the advent of modern critical care, mortality from GBS in children is rare. CHRONIC INFLAMMATORY DEMYELINATING POLYRADICULOPATHY (CIDP) CIDP is a form of inflammatory motor and sensory neuropathy that evolves over a protracted time of more than 4–8 weeks. CIDP is less common than GBS and occurs less frequently in children than in adults. Nonetheless, CIDP represents approxi- mately 10% of all chronic childhood neuropathies. Diagnosis=Clinical Features The classic symptoms and signs of CIDP include largely symmetric weakness in proximal and distal limb muscles, reduced or absent tendon reflexes, and, sometimes, sensory deficits and paresthesias. Most often children present with abnormal gait and frequent falls secondary to weakness of the legs. CIDP may manifest with a chronic progressive, monophasic, or relapsing–remitting clinical course. Weakness is primarily a consequence of conduc- tion block resulting from focal demyelination; as such it often responds well to treat- ment. After years of disease, there can be accumulating axonal degeneration, clinically evident by wasted muscles, which may be irreverisible. There are many causes of symmetrical weakness in children ranging from central nervous system disorders to muscle disease. In patients without sensory symptoms and signs, anterior horn cell disease (spinal muscular atrophy), neuromus- cular junction disease, and muscle disease are important considerations. Neuropathy in children is often due to inherited disorders such as Charcot-Marie-Tooth disease (CMT type 1–4 and X) or less commonly due to inborn errors of metabolism such as Krabbe’s disease, metachromatic leukodystrophy, Refsum’s disease, adrenomyelo- leukodystrophy, or acute intermittent porphyria. A diagnosis of CIDP is made primarily on the basis of nerve conduction studies (Table 4). Although decreased conduction velocities and prolonged distal motor latencies can be seen in both CIDP and hereditary demyelinating neuropathy, CIDP is distinguished by the presence of 172 Sumner Table 4 Clinical and Electrophysiologic Criteria for Childhood CIDP Mandatory clinical criteria Progression of muscle weakness in proximal and distal muscles of upper and lower extremities over at least 4 weeks, or rapid progression (GBS-like presentation) followed by a relapsing or protracted course (>1 year) Major laboratory features Electrophysiologic criteria Must demonstrate at least three of the following four major abnormalities in motor nerves (or two of the major plus two of the supportive criteria) A. Conduction block or abnormal temporal dispersion in one or more motor nerves at sites not prone to compression: a. Conduction block: at least 50% drop in negative peak area or peak-to-peak amplitude of proximal compound action potential (CMAP) if duration of negative peak of proximal CMAP is < 130% of distal CMAP duration. Temporal dispersion: abnormal if duration of negative peak of proximal CMAP is > 130% of distal CMAP duration. Reduction in conduction velocity (CV) in two or more nerves: <75% mean of mean CV value for age minus 2 standard deviations (SD). Prolonged distal latency (DL) in two or more nerves: >130% of mean DL value for age þ2SD. Absent F-waves or prolonged F-wave minimal latency (ML) in two or more nerves: >130% of mean F-wave ML for age þ 2SD. Supportive When conduction block is absent, the following abnormal electrophysiological parameters are indicative of nonuniform slowing and thus of acquired neuropathy: 1. Abnormal median sensory nerve action potential (SNAP) while sural nerve SNAP is normal. Abnormally low terminal latency index: distal conduction distance (mm)= (conduction velocity [m=sec]) Â distal motor latency [msec]). Side-to-side comparison of motor CVs showing a difference of >10 m=sec between nerves. Cerebrospinal fluid (CSF) criteria Protein > 45mg=dL Cell count <10 cells=mm3 Nerve biopsy features Predominant features of demyelination Exclusion criteria A. Clinical features of history of a hereditary neuropathy, other disease, or exposure to drugs or toxins known to cause peripheral neuropathy.

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Minor health scares Health scares have something in common with showbiz celebrities mood disorder dsm code cheap abilify 15 mg, both owing much to the media anxiety nos discount 15 mg abilify. Some appear suddenly and after their ‘fifteen minutes of fame’ disappear as rapidly; others emerge more gradually and remain on the stage for years depression back pain order abilify 10 mg without a prescription, though largely in the background; others still have an initial flurry in the limelight, then fade for a while, only to make periodic comebacks before slowly fading. Here is a far from exhaustive list of scares which have one common feature: they have all been raised in one form or another by patients in my surgery over the past decade. In the event, fears of an upsurge in malignancies resulting from Chernobyl were not realised and the theory about leukemia clusters has not been substantiated. Ten years later an out- break of gastroenteritis traced to beef contaminated with E. The fear of lethal infection was added to existing concerns about food safety, arising from the use of pesticides on plants, antibiotics and other drugs on animals and diverse additives and preservatives. The main consequence is a flourishing trade in bottled water, though this also became the focus of a scare when contaminated stocks provided by a leading supplier had to be removed from supermarket shelves. Signs around canals and waterways warning of the danger of Weil’s disease, a rare infection transmitted by the urine of rats and almost exclusively affecting sewage workers, have led to at least two requests for blood tests in my surgery. Perhaps the greatest irony of the recent wave of scares is that they have taken off at a time when everyday life in Western society is safer than ever and when the quality of our environment and of our food, water and air is higher and more highly regulated than at any time in history. Contracep- tion is risky, but so is unprotected sex and the menopause only brings the choice between worrying about osteoporosis and fractures or the side-effects of HRT. In the context of detailed advice on how to avoid these terrifying infections, the pamphlet’s comment that they are all ‘very rare, and it is unlikely that you or your baby will be affected’ is scarcely reassuring. While ‘breast is best’ and formula feeds potentially harmful, breast milk has also been shown to transmit numerous toxins. The spectre of meningitis, a rare condition whose features are now familiar to millions, hovers over every viral illness which pro-duces a fever and a rash. Jealous at having been left out of earlier health scares, advocates of men’s health have tried to catch up by promoting anxieties about prostate and testicular cancer as well as concerns about falling sperm counts. Key features A number of common features emerge from our brief survey of some of the more significant health scares of the past decade. At the source of each lies a serious disease, often with a powerful symbolic 22 HEALTH SCARES AND MORAL PANICS character. The risk to any particular individual of acquiring this disease may be low, but it is often also either indeterminate or difficult to establish with any accuracy, creating great scope for speculations which invariably feature worst-case scenarios. Though there have been scares in the past, the recent wave is unique in its scope and impact. The diseases at the root of the major scares are generally terrifying and often rapidly fatal. Some are grossly debilitating (Aids, nvCJD), others disfiguring (malignant melanoma). Some cause sudden death in previously healthy individuals (cot death in babies, pulmonary embolism in women on the Pill), others cause lifelong disability (autism). They often appear to strike the most vulnerable, or even if that is not generally the case, as with Aids, ‘innocent victims’—babies infected by their mothers, or recipients of infected blood transfusions—are singled out for particular sympathy. Health scares are all the more frightening when they are associated with some intimate or familiar activity, like sex, eating, sunbathing, putting the baby to bed. The apparently random way in which these demons strike, reinforced by the vogue for quoting risks like gambling odds, encourages gloomy forebodings and reinforces a fatalistic outlook. Health ministers and medical authorities have been criticised for their failings in communicating the subtleties of risk to the public— and thereby inflaming public fears, particularly in relation to mad cow disease and the Pill. In the case of the Pill, the risks are so low that they are difficult to measure and, once measured in large population surveys, it is difficult to distinguish between an increase that is statistically significant and one that is significant in terms of clinical practice. In some cases, for example that of the risk of acquiring nvCJD from eating beef, or that of a child becoming autistic as a result of the MMR vaccine, the risk is impossible to quantify (it may well be non- existent). This has led to the absurd demand from campaigners for proof that there is no risk from beef or the MMR vaccine before they can consider it safe for people to be exposed to these potential sources of disease. The very indeterminacy of the risks involved in most health scares allows those who are so inclined to speculate wildly, thus inflating anxieties further and justifying further official intervention. In the not so distant past the common focus of health scares was the threat of outbreaks of infectious epidemics, which produced 23 HEALTH SCARES AND MORAL PANICS demands for quarantine and other restrictions on trade and travel. But, though popular fears of plague and cholera, typhus and typhoid, were intense and often resulted in social and political strife, they were more episodic and more localised than the recent scares.

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They did this by inserting hydrophobic mesitylene (trimethylben- zene) molecules into the interior of the micelle depression symptoms noise cheap abilify 20 mg amex. The rationale is that the mesitylene molecules will preferentially exist in the hydrocarbon interior of the micelle anxiety xanax and dementia order abilify from india, rather than in the aqueous environment outside the micelle depression kit discount abilify 10 mg, causing the micelle to expand (see Figure 4. MTS materials grown using these expanded micelles have pore sizes from 4. The diagram shows self assembly of the surfactant into micelles followed by condensation of silica around the micelles. After the formation of the silica around the micelles, the micelles are burnt out, leaving pores where the micelles were. The pores are an accurate reflection of the size and shape of the micelles. Expansion of a micelle by inclusion of a hydrophobic guest into the hydrophobic interior of the micelles. The interior of the micelle is similarly water-repellent, and thus is a much more comfortable environment for the guest. The incorporation of the guest into the centre of the micelle causes an expansion, which in turn leads to larger pores in the resultant material. Molecules have to diffuse through the pores to feel the effect of the cata- lytic groups which exist in the interior and, after reaction, the reaction products must diffuse out. These diffusion processes can often be the slowest step in the reaction sequence, and thus pores which allow rapid dif- fusion will provide the most active catalysts. It is another feature of the MTSs that they have quite straight, cylindrical pores – ideal for the rapid diffusion of molecules. One final extension of the original methodology is that different tem- plates can be used to structure the materials. Two of the most useful systems developed were discovered by Tom Pinnavaia of Michigan State University. These methods allow for the complete recovery of template, so that it can be reused, minimising waste in the preparation of the materi- als, and giving a much greater degree of flexibility to the preparation, allow- ing the incorporation of a great variety of other catalytic groups. More recently, many workers have concentrated on controlling the size and shape of particles, with an eye on industrial applications, where such features must be well defined and controllable. Many shapes have been made, including fibres, spheres, plates, as well as membranes cast on 68 D. All these shapes could one day find application, not only in catal- ysis, but in adsorption of e. This chem- istry is based on the fact that the aluminium centres in zeolites cause a negative charge to exist on the framework of the solid; this charge must be balanced by a cation. When the cation is a hydrogen ion (proton), the material is an acid, and indeed some zeolites are very strong acids indeed. However, the acidity of the corresponding MTSs is much lower, and ini- tially this limited their applicability somewhat. Nevertheless, the MTSs are often found to be very effective as mild acid catalysts. Much work has therefore been aimed at the production of other materials using the same concept, but with either different templating systems, or with combina- tions of elements other than Si and Al in the framework. However, many industrial processes are based on the use of very strong acids, and there is great pressure to find replacements for the liquid acids cur- rently used in industrial processes. One method which has been successfully applied to increase the acidity of these systems is the immobilisation of alu- minium chloride onto the pore walls. Aluminium chloride is itself a very strong acid, and is one of the commonest in industrial chemistry. It is used in a wide range of transformations, but cannot be recovered intact from reac- tions. Aluminium chloride has been successfully attached to the walls of HMS materials, without any reduction in activity – i. A major advantage over free aluminium chloride is the ease of removal of the solid catalyst from reaction mixtures, simplifying the process and reducing waste dramatically.

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Other relevant information would include: ° the name and address of the next of kin/carer/guardian ° preferred form of address for the next of kin/carer/guardian ° name and address of the client’s general practitioner ° details of other professionals in regular contact with the client anxiety help generic 15 mg abilify otc. Referral stage One of the key pieces of information to note in the health record is the rea­ son why the client is being seen by your service anxiety 30000 cheap abilify 15 mg buy online. It is often the case that cli­ ents are referred by another health professional or an associated agency such as social services depression test gov 15 mg abilify purchase overnight delivery. In some cases there may be no referring agent, for instance clients who self-refer, or emergency admissions to accident and RECORD KEEPING 47 emergency. You will therefore need to record the circumstances or inci­ dent that has prompted the client’s attendance. Part of the record at this point in the process will include the client’s account of the reason for his or her contact with your service. In some cases it may be appropriate to also make a note about the attitude of the client or the family towards the referral. For example, parents may disagree that an appointment with the clinical psychologist is necessary, but still attend the appointment at the behest of the child’s school. A complete record at the referral stage in the care process will show: ° the name and position of the referrer ° the date of the referral ° the reason for the referral. Key documents to be kept on file: q referral letters/admission forms q reports accompanying referral. Initial assessment Assessment is a process that will involve gathering information through in­ terview, observation, clinical investigations and objective and behavioural tests. The type of information collected will relate to the theoretical ap­ proach of the record’s user (Pagano and Ragan 1992) – so the assessment process of a medic will differ from that of a nurse, and both will differ from that of a therapist. It is essential that, whenever possible, consent is obtained from the cli­ ent before assessment is initiated. This consent must be informed and the clinician has the responsibility to make sure that the client understands the nature of any assessment procedures, their purpose and any risks. Consent, whether it is given verbally, in writing or by implication, must be recorded in the notes. See the section in this chapter on ‘Writing a Careplan’ for a fuller discussion on recording consent and communicating risk. In general, the type of client data that is collected in assessment will in­ clude information about: ° physical signs, symptoms and behaviours that indicate the client’s current health status ° current health care (for example information on medication, other illnesses) 48 WRITING SKILLS IN PRACTICE ° psychological factors (for example mood and client’s response to the problem) ° psychosocial factors (for example culture, religion) ° predisposing factors to the problem ° cognitive skills (for example memory, language skills) ° environment (for example type of housing or support from family) ° lifestyle (for example habits, diet and exercise) ° daily living pattern (for example working, retired or looking after young children) ° self-care abilities ° risk factors (for example is the client prone to falls? In children you will also want to include information about developmental and behavioural patterns (Cohen 1983). Client data is used by the clinician: ° to identify the health problem, formulate a diagnosis and determine the likely prognosis ° to determine the need for further in-depth assessment or referral to other professionals ° to provide a baseline measure for evaluating progress ° to establish the need for intervention and prioritise individual clients within the general caseload ° to help plan intervention and set realistic outcomes ° to help plan for discharge. Taking a case history is an essential first step in collecting relevant client data. Information is usually provided directly by the client, but in some cir­ cumstances another may give it, such as a parent or friend. In the latter case, always record the name and relationship of the informant to the cli­ ent. RECORD KEEPING 49 Write a description of the problem using the client’s own words. Note the way in which it first became apparent to him or her and the develop­ ment of the problem. The onset and sequence of symptoms need to be dated as accurately as possible. Establish whether the problem has changed in character or severity, and note any circumstances that are associated with these changes – also, what does it mean for the client, impact on life­ style, degree of pain and so on. The information provided in the case history will be supported by your clinical observations, and by objective or behavioural tests that help to describe and quantify the presenting problem. This information is the evidence on which your clinical decision making is based and must be clearly recorded in the client’s notes. A set of complete notes will also have a record of planned assessments that were abandoned or postponed. Give the reasons for this: for example, the client was too tired to complete a psychological test, or the client was unable to tolerate a procedure due to the pain. Record how you plan to fol­ low this up: for example, date for a follow-up appointment or referral for an alternative procedure. Once sufficient information has been collected then the clinician is in a position to interpret the data.

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On the basis of his work with Cordier in the anatomy laboratory of the faculté in 1959 lethargic depression definition buy line abilify, he compiled an atlas of hori- zontal cuts of the thorax depression symptoms violence purchase discount abilify on-line, with photographs and illustrations that demonstrated the axial anatomy: Raymond ROY-CAMILLE these images prefigured what would later be 1927–1994 possible with computerized axial tomography depression and loneliness test purchase abilify toronto. After completing his internship, he spent a year Raymond Roy-Camille was born on April 25, in the service of Professor L. Leger was 1927, in Fort-de-France on the island of Mar- also from Martinique, and he took Raymond tinique. Raymond was an active, friendship that lasted for the remainder of their curious child and a serious student. His interest in trau- nated by the work of his uncle and spent much matology and tumors of the spine was particularly time visiting and observing him. He shared Judet’s He completed secondary school in 1945 after interest in the cervical spine, and his innovative having excelled in all of his classes. He established criteria these were the years of World War II, the educa- for the use of a posterior approach for the opera- tional system of Martinique was not disrupted. Raymond moved to France in 1945 at the age of He also described the importance of the midver- 17, just as the war was ending. When he arrived tebral segments and ligamentous injuries of the in Paris, there were continuing post-war restric- cervical spine. During this time, he decided to become a As chief of the department of traumatology and surgeon. He attended undergraduate school from orthopedics at l’Hôpital Intercommunal in Poissy 1945 to 1948 and served as an extern from 1948 from 1970 to 1975, Raymond developed the to 1952 at the Hôpitaux de Paris. He also supervised the construction of a bridges throughout the world as he traveled to heliport so that patients who had acute injuries of lecture on problems of the spine. This was best the spine could be transported more quickly to the exemplified by his collaboration with Carroll A. He was the author of many articles and Cloward, in Honolulu, and Arthur R. His interest in the pathology of the honorary membership in the North American spine, including tumors, infections, and degener- Spine Society. He was an enthusiastic member of ative problems was stimulated even more. He succeeded Sicard and in turn bridge of knowledge between Europe and North was succeeded by Saillant. While in this position, America was also demonstrated by his hosting of Raymond was responsible for many innovative the International Meeting on Spinal Osteosynthe- ideas, particularly pertaining to techniques for sis in December 1992. Raymond and his wife, Chantal, were married Raymond never actually considered himself a in Toulouse in 1976. Their life was accentuated spine surgeon per se but, more appropriately, an by Raymond’s work and travels, as well as his orthopedic and trauma surgeon. They had many friends and a told by Fevre, a general surgeon, that “if you want very busy social life, which they both enjoyed to do something interesting, you must do some- greatly. Raymond died on July 14, 1994, being thing which is difficult and that nobody else wants survived by his wife and a daughter, Julie. She had had a laminectomy previously at another hospital, performed by the neurosurgical team. The fourth lumbar vertebra was still dislocated in the lateral position on the fifth lumbar vertebra and the spine was obviously quite unstable. Raymond stated: The reduction was easy, but I had no more spinous Lowry Rush J. I had no more laminae, and the wires and Wilson plates we had at this time were not helpful. I was an anatomist and I knew about the pedicle; I 1905– understood immediately that a good location to have an implant fixed to the spine was the pedicle. That is how Nowhere is the old adage, “necessity is the I started with this surgery the first time. In 1936, Raymond introduced spinal plating and an encounter with a badly comminuted and con- pedicle-screw fixation to the United States when taminated open Monteggia fracture–dislocation he was the presidential guest speaker at the annual of the elbow demonstrated the value of intra- meeting of the American Academy of Orthopedic medullary fixation to two innovative young Surgeons in San Francisco in 1979. Satisfied with their ing to Garrison and Morton, this is, if not the result, but not with the pin itself, they pursued an first, one of the first pathologic descriptions of interest in the problem of intramedullary fixation, osteonecrosis in medical literature.

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Always check once anxiety vs depression buy discount abilify line, then check twice and depression jealousy purchase abilify 15 mg, if you are tired or inexperienced depression motivation abilify 15 mg online, run through the procedure in you head and check again. During the procedure maintain sterility at all times and, if inexperienced, always ask a senior or a PRHO who is more experienced than you to either supervise or assist you. Do not feel embarrassed if you have to ask your SHO or SpR to supervise you several times, even if they become annoyed. The basic rule is,if you are not confident,do not perform the procedure,as your mistake may have more serious consequences than the initial reason for per- forming it. It is better to irritate your senior by getting them out of bed to per- form a procedure that you are not confident with than cause iatrogenic pathology. This has on more than several occasions resulted in the patient sustaining iatrogenic haemothorax, pneumothorax or both. I have attended a cardiac arrest call for a life-threatening iatrogenic haemothorax secondary to a pleural tap (which thankfully I did not perform,but it can so easily happen to any of us). There was one stupidly simple reason it was not diagnosed earlier – the PRHO who had performed the tap had not written that the tap was‘bloodstained’in the notes. Had the documentation been better the diagnosis would have been made earlier and the patient would have been treated before becoming critically unwell. When performing the procedure keep a mental note of the quantity and type of sharps used. After you have finished clear away your mess – it is your responsibility. Again, a kind nurse may offer to do it for you, in which case accept gladly and then go to write in the notes. However, you should bear in mind that it is your legal responsibility to clear away your own sharps into the sharps box. When disposing of them make sure your mental tally is in keeping with the number you dispose of. If a nurse clears up for you, inform them of the number of sharps on the trolley. Lastly, you need to make a note of the procedure in the patient’s notes. The date, time and your name, grade and bleep number are all requirements. It is important as a PRHO and SHO to try and follow up any patient on whom you have performed a procedure in order to see what the outcome was. If they had a complication was it something that you did badly or was the patient simply very unwell? This is the first step to auditing your own‘outcome measures’ and a very good learning exercise. For example, if you are not sure whether your ‘sterile technique’ was sterile enough, did the patient get an infection afterwards? How to Deal with the Death of Your Patient Death is more common than you may expect (particularly in some specialities such as elderly medicine or vascular surgery) and it is always emotionally difficult. Some of you may have experienced it as a medical student when a patient you have clerked Surviving the Pre-registration House Officer Post 25 Degrees of cleanliness Septic Area cleaned during procedure Non-sterile gloves e. The feeling of loss and lack of power is the same when you are qualified, only magnified. This is because you spend a lot more time with your patients than when an undergraduate and, more importantly, you see their relatives and treat the patient for their disease. Often for the first time you realise that your patients fit into a fam- ily network as you do and that, when they die, it affects everyone. It is difficult when you have been trying to treat disease but the patient is overwhelmed and deteriorates. It is natural to be upset, but you must remember that the only certain thing in life is death. Whether a person dies or not is not always the most important thing – this may sound strange. More importantly is how the patient dies – are they with family, are they comfortable and dignified, or are they alone and suffering in pain and distress fighting for breath?

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Evaluation It is crucial to incorporate a system of evaluation into your project definition of depression in psychology generic abilify 20 mg with visa. This will help improve the planning and execution of your present task as well as providing valuable insight for use in any future projects depression killing me buy discount abilify 20 mg on line. The development stage A system for continuous review of the development process needs to be scheduled right at the start of your project definition depression bei kindern buy abilify 20 mg cheap. You will want to evaluate: (a) Timescales (b) Costs (c) Resources (d) Development team (e) Development process. INFORMATION LEAFLETS FOR CLIENTS 115 (b) Costs Developing written materials is a costly process. However, there are hidden costs that need to be accounted for when calculating the overall expense. For in­ stance, a one-hour planning meeting with four people is equivalent to four hours in terms of salaries. Continuous review of expenditure is needed if costs are not to esca­ late beyond your planned budget. Were all the resources that you required readily available, for example access to an evidence base via a library or a graphic artist for illustrations? The emphasis is on how you developed the materials and whether these procedures worked well. The validity of your written material Use the following checklist to help in evaluating the validity of your writ­ ten material: q Is it accurate? The effectiveness of your written material Evaluate the outcomes of your project. A first review might be best 12 months after the completion of your project. This is a fundamental question but not necessarily one that is easy to answer. There are a number of different methods you can use to help you evaluate the effectiveness of your written material. Try one or a combination of the following ways: ° User feedback from clients, clinicians and administrative staff. Feedback might be obtained via focus groups, questionnaires or more general sources like the organisation’s information officer. Putting a date for review on material is one way of helping to ensure this happens at the right time. The purpose of these reviews will be: ° to update the information with current knowledge and practice ° to monitor accessibility ° to review the timing of the delivery of the information ° to update the information to reflect changes in legislation ° to update the information to reflect current health and social policies ° to amend any inaccuracies. You will need to decide who has responsibility for carrying out these re­ views and make contingency plans in the event of staff changes. INFORMATION LEAFLETS FOR CLIENTS 117 Summary Points ° Most written material benefits from a team approach to its development, writing and production. PART TWO W riting for T eaching and Learning W riting for Teaching and Learning Teaching and learning is an integral part of the health profes- sional’s working life. All clinicians have to undergo formal training and assessment in order to obtain a qualification. Note-taking, writing essays and completing exams are famil­ iar student activities. Once qualified the clinician is likely to return periodically to the learner role, either by attending continuing education programmes or, more formally, by en­ rolling as a postgraduate student. In addition, many clinicians are now involved as educators themselves and are writing teaching materials, and setting and marking coursework. The main section of this part looks at writing as a learning medium and preparing materials for teaching. It includes ad­ vice on how and where to search for information and the use of effective reading strategies – skills that are of use not only to the student but also to clinicians wishing to review the lit­ erature either for research purposes or to establish an evi­ dence base.

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It will appear depression pain discount abilify 20 mg with mastercard, and actually be mood disorder resources abilify 15 mg order free shipping, more manageable and therefore achievable depression quotes images purchase 20 mg abilify visa. Others may be achieved by adapting your knowledge and skills from other areas. For example, research skills used as a stu­ dent preparing project work are easily adapted for researching material for a book. Study how others carry out activities you are unfamiliar with, or get specific help from someone who does know. For instance, librarians will offer help in carrying out data­ base searches and libraries often run general training sessions. Break down into smaller steps, utilise what you know al­ ready, and plan how to find out the rest. Task is unpleasant – what is it that makes this task unpleasant for you? Think about small rewards that you can give yourself when you have completed each stage. You will always have requests, demands and pleas from others to become involved in activities that will take you away from your writing. Start thinking about time away from your writing as ‘mortgaged time’ (Garratt 1985). Complete an activity record Use the activity record to record your daily activities (see Figure 15. Select one or two of the most important activities for recording, or alternatively use an umbrella term such as ‘sorting post’. Continue to record events on a daily basis until you have established the pattern of how you spend your time. Remember this information is entirely for your personal use, so be honest with yourself. Write what you do, and not what you would like to do or feel you should be doing. Once this is completed, your next step is to ana­ lyse your activity records. Making sense of the information in your activity record Use the information in your activity record to find out what you do, when you do it and how long it takes you. List the different activities from your record under general headings like work, home or leisure. Here are some suggestions for different categories: ° work ° social ° routine home ° personal ° hobbies/interests ° study ° writing ° family ° other obligations. Start calculating how much time is spent on each area throughout the week. If necessary you may want to further subdivide the information in each of your categories. For instance, leisure time may be divided between sports, hobbies and going to the cinema. You will now have a clear idea of what you do with your time, and how much time you spend on certain activities. This information can be usefully displayed in the form of a Gantt chart. Place time along the horizontal axis, and activities on the vertical axis. Mark the days along the horizontal axis, and the activities on the vertical axis. MANAGING YOUR TIME EFFECTIVELY 245 Use various styles of shading to represent different activities. For in­ stance, you can use solid shading to block out the days you are in work and cross-hatching for Saturday morning when you normally do your shop­ ping. This type of visual display is useful for highlighting any activities that impinge on other areas.

Rocko, 52 years: Some moderators prefer to use a list of questions as their interview schedule, whereas others prefer to use a list of topics (see Chapter 7 for more information on developing an interview schedule). However utilizing second- generation technique, there has been only 1 loosening and 2 radiolucencies in the most recent 138 hips, and none when the stem was cemented in despite the pres- ence of large cystic defects. He was educated at Herstmonceux Perkins had a realistic appreciation of his abil- School, Hertford College, Oxford, and St. Septic shock produces more drastic See also Bacteriocidal, bacteriostatic symptoms, including elevated rates of breathing and heartbeat, loss of consciousness and failure of organs throughout the body.

Gorn, 24 years: For many years, he involved duties and contacts of every description, worked in trusted collaboration with this univer- but the young surgeon fresh from the university sally recognized surgeon, who may be said to received as kind and as amicable a welcome as have been the founder of the modern technique of the VIP. Thus, having to pay out of pocket prevents many people from accessing alternative health care and is frequently cited as an explanation for the greater prevalence of use of alternative therapies among people with higher incomes (Eisenberg et al. A1 and A2 represent the yield points; B1 and B2 represent the ultimate tensile strength; cross-hatched areas represent the material toughness. Six months of this Journal of Bone and Joint Surgery than his series time was spent in Baltimore on the service of Pro- of contributions on disorders of bone growth?

Kayor, 57 years: Mr Travers departure was made the occasion for the appreci- saw him with me and agreed in this opinion. This staggered cut leaves a pair of identical single special enzyme activity that helps in the insertion of Diagram showing specific base pairing found in DNA and RNA. Valproic acid is still often regarded as a drug of choice because of its broad spectrum of activity; however, seizure control is achieved in only 10–30% of patients. Working as a general practitioner, I am struck by the contrast between two types of patient.

Hengley, 48 years: Reliable, valid, and clinically sensitive tools exist to assess pain in children from neonates to adolescents. He was also director of the Beckman Center for particles and foreign organisms by immune cells (a phenome- Molecular and Genetic Medicine (1985), senior postdoctoral non termed phagocytosis), and the enhanced immune reaction fellow of the National Science Foundation (1961–68), and of an organism to an antigenic target (called anaphylaxis). There may be a lot of synovium and fat pad that needs to be removed with a shaver in order to visualize the meniscus. Enabling this to occur may involve the whole team in teaching techniques, procedures and instruction in the use of equipment to both patient and family.

Benito, 44 years: I then concentrated on listening, probing to explore issues informants raised and to seek clarification, and noting when there were pauses in the conversation. Extrinsic Conditioning Many authors believe that the novice female athlete is introduced to activities that are beyond her physical conditioning. After this, I readdress the risk of mortality in a more general way and stress our inability to predict for specific indi- viduals. However, other high-risk body fluids, HIV such as semen, vaginal secretions, and cerebrospinal, synovial, ● Seroconversion from known positive donor pleural, peritoneal, pericardial, and amniotic fluids, should 30% HBV have the same universal precautions applied.

Umul, 21 years: Manual reduction is commonly used when the physeal stability is rated as unstable, and it reportedly entails a rather reduced risk of avascular necrosis of the femoral head if performed with tender care. He made experimental and, in addition, late in life displayed remarkable studies on bone grafts and on epiphysial cartilage originality. When he took over the editorship, the Journal The years immediately following the founda- had not progressed very far beyond the transac- tion of the Association, in 1887, were years tions stage of its evolution. His loss is a sore one for, among his and Brockman at Chailey Heritage; proceeding to many qualities, was an outstanding ability to per- FRCS in 1934.

Sancho, 35 years: Clear intubation trainers, and other required guidelines are available from the Resuscitation Council (UK) training aids detailing how relatives should be supported during cardiopulmonary resuscitation procedures. A further multiple choice paper, which includes questions on rhythm recognition, is undertaken. Many drugs and agrochemicals can exist as two forms which are mirror images of one another, only one of which is useful, the other being useless or even dan- gerous. Objectives provide a guide to teachers and to students, but should not be so restrictive as to prevent the spontaneity that is so essential to the higher education of students.

Gancka, 53 years: Pharmacological treatment with atypical antipsychotics or anticonvulsants may be tried but there is no secure evidence base. Small children can be splinted to a child seat with good effect—padding is placed as necessary between the head and the side cushions and forehead strapping can then be applied. In Chapter 9 we give you more information about preparing and using these systems. However, you may initially find sessions of this type hard going if the students are not used to the challenge of this method of teaching.

Dan, 39 years: Most clinical education still happens in hospitals, so students gain little insight into how patients function at home or rebound from acute short-term de- bilities. There must be a clear distinction between the student’s original ideas and the work of other researchers. Contemporary Western society now faced quite different health problems: heart attacks, strokes and cancer were the major killers, especially of older people, and arthritis, diabetes, asthma were the major causes of ill health. Available directed history of the seizure episode and the child’s previous medical history should be obtained and the child examined.

Xardas, 22 years: Both and most of the radiation continues along its original path, but a are caused by spirochetes. The in the presence of oxygen and the appropriate cofactors, these most common use of bioremediation is the metabolic break- components will produce light with an intensity dependent on down or removal of toxic chemicals before or after they have the quantity of luciferin and luciferase added, as well as the been discharged into the environment. In problem based learning (PBL) students use “triggers” from the problem case or scenario to define their own learning objectives. Sulphur and phosphorus are also needed for the man- cisely at the middle of the bacterium.

Sven, 43 years: Postoperative Treatment All patients began straight leg-lifting excises from the day after surgery and used wheelchairs for 4 weeks. He and his wife, Betty, occupied an in-law apart- ment upstairs in their daughter’s home outside a New England picture postcard town. As the materials are being carried into structure), transmembrane proteins form hydrophilic (water lov- the cell, the cell membrane pinches in forming a vacuole or ing) channels to through which water molecules may move. To North Ian MACNAB Americans, his knowledge and expertise, com- bined with his command of the English language 1921–1992 and his Churchillian oratory, made him one of the most sought-after orthopedic lecturers and visit- Ian Macnab was the son of a Scottish shipbuilder ing professors.

Kippler, 62 years: It is essential that the senior doctor and nurse at the cardiac arrest should debrief the team, whether resuscitation has been Practising in the resuscitation training room successful or not. No account of Dillwyn’s services to orthopedic surgery would be complete without reference to the man himself. TV companies already employ market researchers to conduct a great deal of research into public viewing, and they have much larger budgets available to them. Brainstem and=or cerebellar dysfunction can appear or worsen in adulthood.

Candela, 29 years: Vincristine must be avoided in children with Charcot–Marie–Tooth disease, in which there is risk of irre- versible paralysis with administration of the drug. For example, it often occurs at knots or twists in monofilament wire or where kinking has occurred. The DNA strands are separated by enzyme cell division takes place through cytokinesis. Establish whether the patient is responsive by gently shaking his or her shoulders and asking loudly “Are you all right?

Ugo, 60 years: My parents didn’t really sit my brothers and me down—we were all under eight—and try to explain what is going on with Dad. When assisting an operation as a teacher, he would ensure that no mistakes were made, and was even known to have tapped an errant student’s hand with a clamp. Diphtheria is apparent as an inflammation and Director of the Center for Biofilm Engineering at Montana bleeding of the throat and as a generalized toxic poisoning of State University, Bozeman. As doctors will remember from being a student, patients often open up to and tell students their worries, as they do not wish‘to bother the doctor’.

Wilson, 42 years: The orthopedic hospital was to be not found it expedient to lay hands on the few remain- merely a place to which patients came to seek ing copies of Girlestone’s monograph and send relief, but rather a center from which workers them overseas with the advice that no better went out into neighboring towns, villages and guidance was obtainable anywhere. In his earlier years, he would work all week in New York City, then fly to Vermont to teach and operate over the weekend, and return home to Harold Hamlyn BOUCHER begin again early Monday morning. Thus, the knowledge and experience of the Many years of cooperation with the famous bone Langenskiöld school have spread all over the 187 Who’s Who in Orthopedics country for the benefit of patients in need of Hospital, Cleveland, Ohio, and his orthopedic orthopedic surgical treatment. John said something else that became an essential fabric of my exis- tence: the course of MS is unpredictable, so I would have to live with un- certainty.

Sinikar, 45 years: His writings are a bottomless source of ideo, the place where he mostly taught. On radiographic evaluation, radiographic progression was observed in 73% of hips in the study by Urbaniak et al. He returned from Egypt with two war deco- rations, one the Companion of the Bath and the other the Companion of St. Central Nervous System Infectious Diseases andTherapy, edited by Karen L.

Hurit, 56 years: It should not be a final choice in young patients because new problems such as pros- thetic wear, osteolysis, and loosening have developed in THA, requiring later revision surgery. If the group is suspicious, do you intend to be completely honest about who you are and what you’re doing? Doctors could now play a role in society, not in alliance with mass democratic social movements, but only as agents of the state. In our view, it is among the most educationally promising ideas in recent years, and we suggest you study the book by Boud listed at the end of this chapter.

Grubuz, 40 years: However, the conclusions are attempting to create a vaccine from a single virus protein. Her personality fit with her job as a television producer but it did not serve her well as a mys- tery malady patient. Evidence clearly suggests that Medicare MCOs have systematically sought “healthier” members, avoiding persons with chronic disease and dis- ability. Such con- fident pronouncements tapped into my uncertainty as a relative newcomer to disability.

Uruk, 47 years: I have listened to my patients who have from time to time complained about side effects of medications I prescribed, and I dismissed them if I couldn’t find any literature or findings that would sup- port their complaints. Sessions are timetabled for practising skills learnt during the teaching session. On the other hand, careful postoperative management is necessary, especially for moderate and severe slips. These provide dual-chamber pacing and can also distinguish atrial from ventricular tachyarrhythmias.

Rendell, 61 years: Noulis studied in Paris for 5 years, months before his death he gained particular receiving further training in internal medicine and pleasure from being able to travel to Aberdeen for general surgery. Primary Dystonia The major form of primary dystonia in children is childhood onset, generalized, idio- pathic torsion dystonia, formerly known as dystonia musculorum deformans. HOW TO CARRY OUT PARTICIPANT OBSERVATION/ 107 Most of your analysis takes place in the field so that you can cross check and verify your hypotheses. Forced groping may be conceptual- ized as an exploratory reflex which is “released” from frontal lobe control by a pathological process, as in utilization behavior.

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