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This will necessarily include the adaptation of restricting areas: changing attitudinal barriers to treating people as people first and as citizens with equal rights (but perhaps with differing levels of need depending on the impairment experienced which should be met without charge or censure) order 160 mg super p-force oral jelly free shipping. Models of disability There are two models of disability with which I am mainly concerned: the first is called the ‘medical’ model and the second cheap super p-force oral jelly 160mg overnight delivery, the ‘social’ model of disability super p-force oral jelly 160 mg line. It is important to understand these two models because they help to clarify differences in professional perceptions cheap super p-force oral jelly 160mg with visa, although discount super p-force oral jelly 160 mg with visa, it has to be said, models are just that: not the reality of experience, but a means 18 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES towards understanding, in these examples, the experiences of people with disabilities. The medical model (Gillespie-Sells and Campbell 1991) views disability as a condition to be cured, it is pathological in orientation and ‘consequently’ is indicative that a person with disabilities has a medical problem that has to be remedied. This portrays the disabled person as having a problem or condition which needs putting right and this is usually achieved by following some form of treatment, which may be perfectly acceptable in a patient–doctor relationship when it is the patient who is seeking treatment. It is, however, questionable when the patient is not seeking treatment, but because of a disability may be expected to go for medical consultations to monitor their condition when this may achieve little or nothing. Considering the individual only in treatment terms is to allow the pathological to override the personal, so that the person becomes an object of medical interest, the epileptic, the spastic quadriplegic, the deaf, dumb and blind kid who has no rights. A social model, on the other hand, indicates that disability is exacerbated by environmental factors and consequently the context of disability extends beyond the individual’s impairment. Physical and social barriers may contribute to the way disability is experienced by the individual (Swain et al. Questions may be asked, following the suggestions of Oliver (1990) such as, ‘What external factors should be changed to improve this person’s situation? This is like saying that a disabled person must be monitored by a consultant rather than visiting their general practitioner when a need to do so, as with all of us, is thought advisable. Consequently, in the school example, mainstream education might be preferable for many or most children with disabilities, but is only viable if accompanied by participative policies of inclusion and encouragement for the child at school, together with classroom support. The social model should promote the needs of the individual within a community context in such a way that the individual should not suffer social exclusion because of his or her condition. In the THEORY AND PRACTICE / 19 example given, rather than withdrawing the child from the everyday experiences of others, integrated education would mean that he or she is part of the mainstream: it is a kind of normalisation process. The social model simply encourages changes to be made to the social setting so that the individual with some form of impairment is not disadvantaged to the point of being disabled by situational, emotional and physical barriers to access. The world, however, is not so simplistically divided, for where the doctor cannot cure, surgery can at times alter some elements of the disability, by, for example, operations to improve posture and mobility, although ‘the need’ for major surgery may provoke controversial reactions (see Oliver 1996). One view expressed by some people with physical dis- abilities is that a disabled person should not try to enter the ‘normal world’. This reaction is a consequence of viewing medical progress as a way of overcoming disability by working on the individual with an impairment, who is made to feel abnormal and disabled, rather than viewing the impairment as a difference, which should be understood by those with no prior experience of the condition. The first model assumes that people are disabled by their condition, the second by the social aspects of their experiences which give rise to feelings of difference that portray the individual as disabled. This locates disability not within the individual but in their interactions with the environment. In practice, the emphasis should rest between a careful assessment of personal circumstances in each individual case and a full consideration of the consequences of wider structural changes. The latter should benefit all people with impairments when accessing resources, which may be automatically allocated to meet the needs of the non-disabled majority. For example, in providing lifts for wheelchair access to multistorey buildings, ambulant people might not perceive a problem, while those in wheelchairs experience restrictions. In brief, then, the medical model on the whole emphasises the person’s medical condition, illness or disability as being different from the norm. The social model of disability tends to be holistic, placing the individual in his or her context and focusing on the duty of others to effect change, so that the behaviour of others and the opportunities offered do not promote 20 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES a sense of disability as a condition to be discriminated against, ignored or avoided. Impairments should not of themselves be restrictive if barriers, attitudinal and physical, are eliminated. The medical and social models are not intended to represent a right or wrong way of looking at the world: both are limited, both have their place. Identifying an integrated model Some years ago I suggested reconstructing the social model (Burke 1993) to reflect a person-centred approach. This may be viewed as a contradic- tion in terms, given that the medical view is at the level of the personal and the social at the level of the community. The latter suggests that major societal changes are required to remove disability, but at the level of an individual impairment, personal assistance may be required. This is where the medical and social intersect, and planning is needed to work with people with disability, whether children, adults or siblings. This planning would be based on an assessment of need, which should assist the user to overcome any barriers or difficulties encountered through impairment, whether it be gaining access to buildings or resources or linking to barriers of a social, or attitudinal form.

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Which of the following statements regarding the treatment of this patient is true? One positive blood culture with Salmonella suggests an endovascu- lar nidus of infection B generic 160mg super p-force oral jelly. No patient with Salmonella gastroenteritis should be treated with antibiotics because treatment merely prolongs the carrier state C purchase super p-force oral jelly 160 mg amex. The decision to use antimotility agents such as Lomotil (diphenoxy- late hydrochloride with atropine sulfate) should be based on the number of stools passed per day D purchase super p-force oral jelly 160mg online. Erythromycin is the treatment of choice for gastroenteritis caused by Campylobacter if antibiotic therapy is deemed necessary 30 BOARD REVIEW E discount super p-force oral jelly 160 mg with visa. Antibiotic treatment is indicated for Shigella gastroenteritis to short- en the period of fecal excretion Key Concept/Objective: To understand the basic concepts of the treatment of infectious diarrhea Treatment of infectious diarrhea of most causes mostly involves supportive care generic super p-force oral jelly 160mg line. However, it is important to recognize specific indications and contraindications of cer- tain treatments. Campylobacter enteritis is usually self-limited; therefore, specific ther- apy is often unnecessary. However, it may be prudent to administer antibiotics to those patients with moderately severe disease as well as to immunosuppressed patients, preg- nant women, or patients with symptoms that worsen or persist for more than 7 days after diagnosis. For Campylobacter enteritis, erythromycin is the treatment of choice. For Salmonella gastroenteritis, treatment may prolong the carrier state. However, antibi- otics should be administered to patients who are severely ill or who are at risk for extraintestinal spread of infection; these patients include infants, persons older than 50 years, patients with cardiac valvular or mural abnormalities, patients with prosthetic vascular grafts, and those receiving immunosuppression. Quinolones or third-genera- tion cephalosporins are optimal. Nontyphoidal Salmonella has a propensity to colonize sites of vascular abnormality such as prosthetic vascular grafts, atherosclerotic grafts, and aneurysms. The presence of high-grade bacteremia (more than 50% of three or more blood cultures are positive) is suggestive of an endovascular infection. For Shigella gastroenteritis, antibiotics are not essential; however, for isolates that are known to be susceptible, ampicillin or tetracycline has been shown to shorten the clinical illness and the period of fecal excretion. Generally speaking, antimotility agents such as Lomotil should not be used in patients with infectious diarrhea. A 68-year-old man presents to the emergency department with productive cough, shortness of breath, dizziness, and fever. His symptoms began 2 days ago and have been worsening. On presentation, the patient is febrile, hypoxic, tachycardic, and mildly confused. Chest x-ray shows an infiltrate in the left lower lobe. Pseudomonas aeruginosa, Legionella pneumophila, Haemophilus influenzae, and Moraxella (Branhamella) catarrhalis generally are readily apparent on sputum Gram stain as gram-negative rods B. A third-generation cephalosporin would cover all important poten- tial gram-negative pathogens D. The development of an empyema would be uncharacteristic of a gram-negative pathogen Key Concept/Objective: To understand various gram-negative pneumonias P. Legionella organisms are poorly seen on routine Gram stain, but visualization of these small, pleomorphic gram-negative bacilli is improved if basic fuchsin is used as 7 INFECTIOUS DISEASE 31 the counterstain in place of safranin O. The clinical fea- tures are those of a mild, acute pneumonia. Most of the isolates in these cases are nontypeable strains not affected by the vaccine active against the type b capsular polysaccharide. Suppurative complications such as empyema can certainly be seen in pneumonia caused by H. He reports having episodes of severe coughing, and he has even experienced eme- sis with severe coughing spells. In your differential diagnosis, you consider Bordetella pertussis infection and atypical pneumonia. Which of the following statements is true regarding B. Diagnosis can be reliably confirmed by use of acute and convales- cent antibody titers E.

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The dramatic differences between the Asian and Western diets possibly contribute to the significant difference in risk super p-force oral jelly 160 mg line. Data from large cohort studies and case-control studies support the contentions that red meat generic 160 mg super p-force oral jelly with amex, animal fat super p-force oral jelly 160 mg generic, and total fat consumption increase the risk of prostate cancer cheap super p-force oral jelly 160 mg with visa. In the Health Professionals Follow-up Study order 160 mg super p-force oral jelly with mastercard, men with lower testosterone levels who subsequently devel- oped prostate cancer were more likely to develop higher-grade prostate cancer. A 58-year-old white man presents to your clinic with a chief complaint of frequent urination. Other results of the physical examination are normal. For this patient, which of the following statements regarding screening for prostate cancer is true? Most cancers detected by DRE are confined to the prostate and are usu- ally curable 12 ONCOLOGY 21 B. PSA is a glycoprotein with serine protease activity; it is a member of the kallikrein family and is produced only by malignant prostatic epithelial cells C. Biopsy of the prostate in men who have moderately elevated PSA levels (i. Prostate cancer is more likely when the total PSA level is high and the percentage of free PSA is low Key Concept/Objective: To understand that the goal of screening for prostate cancer is to detect organ-confined prostate cancer that is potentially curable Optimal screening for prostate cancer combines use of the PSA test and the DRE. Historically, DRE was used to screen for prostate cancer. DRE is inadequate, however, because its interpretation is highly variable, many cancers are not palpable, and most can- cers detectable by DRE are not organ confined and therefore are incurable. PSA, a glyco- protein with serine protease activity in the kallikrein family, is abundant in semen, where it dissolves seminal coagulum. Both normal and malignant prostatic epithelial cells pro- duce PSA; production may actually be higher in normal cells than in malignant cells. A problem with PSA-based screening is that an elevated PSA level lacks specificity. Despite the increased likelihood of prostate cancer in men with a moderately elevated serum PSA level (i. PSA derived from malignant epithelial cells tends to bind more avidly to serum proteins. Thus, in men with an elevated serum PSA level, cancer is more likely when the percentage of free PSA is low. The biopsy is performed transrectally with ultrasound guidance, and mul- tiple samples are obtained. However, one sample reveals prostate intraepithelial neoplasia (PIN). For this patient, which of the following statements regarding the diagnosis of prostate cancer is true? The most common prostate cancer is squamous epithelial cancer B. The most commonly used grading system for prostate cancer is the Gleason grading system C. PIN is a premalignant state; once diagnosed, further prostate biopsies are not indicated D. Clinical staging of prostate cancer relies on CT imaging and bone scan- ning to determine degree of metastatic disease Key Concept/Objective: To understand the role of multifactorial assessment in the diagnosis and stratification of patients with prostate cancer The vast majority of prostate cancers are adenocarcinomas; small cell carcinomas, squa- mous cell carcinomas, and sarcomas are uncommon. The most commonly used grading system is the Gleason grading system, in which tumors are classified by the degree of dis- organization of glandular structures. PIN represents a premalignant state; it is felt to pre- date true carcinoma and often coexists with carcinoma in the prostate gland. When biop- sy reveals PIN but no actual cancer, further biopsies are warranted. The clinical stage of prostate cancer is based on the extent of disease assessed by palpation during DRE.

Excessive caffeine use may be a contributing factor here order super p-force oral jelly 160 mg online, but caffeine typically impedes sleep initiation rather than causes early-morning awakenings purchase 160 mg super p-force oral jelly visa. The most likely explanation for this patient’s current fatigue is masked depression cheap super p-force oral jelly 160mg fast delivery, in which mood disturbance is not a prominent feature but anhedonia and insomnia are purchase super p-force oral jelly 160mg visa. The use of benzodiazepines generally should be avoided in patients with a history of alcohol dependence generic super p-force oral jelly 160mg mastercard. A 12-year-old boy is seen for evaluation of several episodes of confusion and inappropriate behavior in the middle of the night. The patient has no symptoms during the day and is able to return to sleep after these nocturnal episodes. He is healthy, takes no medications, and is progressing well in school; family support is strong. Which of the following is the most likely explanation for this patient’s problem? Drug withdrawal Key Concept/Objective: To understand the classification of partial arousal disorders Partial arousal disorders include confusional arousals, sleepwalking (somnambulism), and sleep terrors (pavor nocturnus). These conditions are a subset of the parasomnias: disorders that occur during the sleep-wake transitions and during partial arousals. Parasomnias are characterized by abnormal movements or behaviors that intrude into sleep without dis- turbing sleep architecture. An overnight sleep study with simultaneous video recording can confirm unusual movements or behavior during nighttime sleep in patients with para- somnias. This patient has confusional arousals, which are characterized clinically by mild automatic and inappropriate behavior and confusion; they occur during slow-wave sleep. Sleepwalking is common in children between 5 and 12 years of age; most episodes last 10 minutes or less. There is a high probability that patients with sleepwalking have a family history of sleepwalking. Many patients with sleep terrors also have sleepwalking episodes. A 17-year-old woman presents to her primary care physician complaining of excessive tiredness. This has become increasingly serious for her over the past year. She falls asleep easily at night and generally is in bed at 10:00 P. She is an above- average student, uses no recreational drugs or alcohol, and is not sexually active. Her body weight, complete blood count, and TSH level are normal. What should be the next step in this patient’s workup? Assessment of serum free T3 level Key Concept/Objective: To understand the presentation of narcolepsy without cataplexy Narcoplepsy is characterized by “sleep attacks” and cataplexy. The narcoleptic attacks begin between ages 15 and 25 years, and the prevalence of this disorder is higher in patients with a family history of narcolepsy. The manifestations include an irresistible urge to fall asleep at inappropriate times; attacks last less than 30 minutes. Most patients experience cataplexy (a transient loss of muscle tone) after several 38 BOARD REVIEW years of narcolepsy. Multiple sleep-onset latency testing can be useful in diagnosing narcolepsy (sleep-onset latency refers to time to uncon- sciousness after attempting sleep; normal is about 5 minutes). A finding of sleep-onset latency of less than five minutes with REM sleep occurring in two out of five nap studies supports the diagnosis of narcolepsy. A 52-year-old man presents with increasing fatigue of 2 years’ duration. He has a history of mild hyper- tension without end-organ changes, which is being treated with a diuretic. He naps during the day for about 30 minutes when he can and almost always falls asleep while watching the news after work. Serum electrolytes are remarkable for a potassium level of 3. Which of the following is the most likely cause of this patient’s fatigue? Cerebrovascular disease Key Concept/Objective: To understand the presenting complaints of patients with excessive day- time somnolence Patients with excessive daytime somnolence (EDS) commonly awaken in the morning not feeling refreshed.

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