With the at tacks of September 11 virus living or not generic cefadroxil 250mg fast delivery, 2001 antibiotic resistance vertical horizontal discount cefadroxil 250mg line, and other acts of terror antibiotics for dogs bacterial infections cheap cefadroxil 250 mg fast delivery, the wars in Iraq and Afghanistan antibiotic spectrum purchase 250 mg cefadroxil visa, disas trous hurricanes on the Gulf Coast antibiotic question bank generic cefadroxil 250mg visa, and sexual abuse scandals antibiotic treatment for mastitis cheap cefadroxil 250 mg with visa, trauma has moved to the fore front of national consciousness. However, the first National Comorbidity Study established how prevalent traumas were in the lives of the general popu lation of the United States. In the study, 61 percent of men and 51 percent of women re ported experiencing at least one trauma in their lifetime, with witnessing a trauma, being involved in a natural disaster, and/or experi encing a life-threatening accident ranking as the most common events (Kessler et al. In Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, 71. For behavioral health service providers, trauma-informed practice offers many oppor tunities. It reinforces the importance of ac quiring trauma-specific knowledge and skills to meet the specific needs of clients; of recog nizing that individuals may be affected by trauma regardless of its acknowledgment; of understanding that trauma likely affects many clients who are seeking behavioral health ser vices; and of acknowledging that organizations and providers can retraumatize clients through standard or unexamined policies and practices. Although many individuals may not identify the need to connect with their histo ries, trauma-informed services offer clients a chance to explore the impact of trauma, their strengths and creative adaptations in manag ing traumatic histories, their resilience, and the relationships among trauma, substance use, and psychological symptoms. Organizational investment in developing or improving trauma-informed services may also translate to cost effective ness, in that services are more appropriately matched to clients from the outset. Clients and staff are more apt to be empowered, invested, and satisfied if they are involved in the ongoing development and delivery of trauma-informed services. An organization also benefits from work de velopment practices through planning for, attracting, and retaining a diverse workforce of individuals who are knowledgeable about trauma and its impact. Developing a traumainformed organization involves hiring and promotional practices that attract and retain individuals who are educated and trained in trauma-informed practices on all levels of the organization, including board as well as peer support appointments. Even though investing in a traumainformed workforce does not necessarily guar antee trauma-informed practices, it is more likely that services will evolve more profi ciently to meet client, staff, and community needs. Counselors must be aware of traumarelated symptoms and disorders and how they affect clients in behavioral health treatment. All treatment staff should recognize that traumatic stress symptoms or trauma-related disorders should not preclude an individual from mental health or substance abuse treatment and that all co-occurring disorders need to be addressed on some level in the treatment plan and setting. In addition, assisting a client in achieving abstinence builds a platform upon which recovery from traumatic stress can proceed. Sub stance abuse is known to predispose people to higher rates of traumas, such as dangerous situations and accidents, while under the in fluence (Stewart & Conrod, 2003; Zinzow, Resnick, Amstadter, McCauley, Ruggiero, & Kilpatrick, 2010) and as a result of the lifestyle associated with substance abuse (Reynolds et al. In addition, people who abuse sub stances and have experienced trauma have worse treatment outcomes than those without histories of trauma (Driessen et al. Many individuals who seek treatment for substance use disorders have histories of one or more traumas. More than half of women seeking substance abuse treatment report one or more lifetime traumas (Farley, Golding, Young, Mulligan, & Minkoff, 2004; Najavits et al. Trauma and Mental Disorders People who are receiving treatment for severe mental disorders are more likely to have histo ries of trauma, including childhood physical and sexual abuse, serious accidents, homeless ness, involuntary psychiatric hospitalizations, drug overdoses, interpersonal violence, and other forms of violence. Traumatic stress increases the risk for mental illness, and findings suggest that traumatic stress increases the symptom severity of men tal illness (Spitzer, Vogel, Barnow, Freyberger & Grabe, 2007). These findings propose that traumatic stress plays a significant role in per petuating and exacerbating mental illness and suggest that trauma often precedes the devel opment of mental disorders. As with trauma and substance use disorders, there is a bidirec tional relationship; mental illness increases the risk of experiencing trauma, and trauma in creases the risk of developing psychological symptoms and mental disorders. If a system or program is to support the needs of trauma survivors, it must take a systematic approach that offers trauma-specific diagnostic and treatment services, as well as a trauma-informed environment that is able to sustain such services, while fostering positive outcomes for the clients it serves. These principles comprise a com pilation of resources, including research, theo retical papers, commentaries, and lessons learned from treatment facilities. Key elements are outlined for each principle in providing services to clients affected by trauma and to populations most likely to incur trauma. Although these principles are useful across all prevention and intervention services, settings, and populations, they are of the utmost im portance in working with people who have had traumatic experiences. Although not every client has a history of trauma, those who have substance use and mental disorders are more likely to have expe rienced trauma. Being trauma aware does not mean that you must assume everyone has a history of trauma, but rather that you antici pate the possibility from your initial contact and interactions, intake processes, and screen ing and assessment procedures. Even the most standard behavioral health practices can retraumatize an individual ex "Trauma-informed care embraces a per spective that highlights adaptation over symptoms and resilience over pathology. For example, a counselor might develop a treat ment plan recommending that a female cli ent-who has been court mandated to substance abuse treatment and was raped as an adult-attend group therapy, but without con sidering the implications, for her, of the fact that the only available group at the facility is all male and has had a low historical rate of female participation. Trauma awareness is an essential strategy for preventing this type of retraumatization; it reinforces the need for providers to reevaluate their usual practices. Fami ly members frequently experience the trau matic stress reactions of the individual family member who was traumatized. These repetitive experiences can increase the risk of secondary trauma and symptoms of mental illness among the family, heighten the risk for externalizing and internalizing behavior among children. Hence, prevention and intervention services can pro vide education and age-appropriate program ming tailored to develop coping skills and support systems. A trauma-aware workplace supports supervi sion and program practices that educate all direct service staff members on secondary trauma, encourages the processing of traumarelated content through participation in peersupported activities and clinical supervision, and provides them with professional develop ment opportunities to learn about and engage in effective coping strategies that help prevent secondary trauma or trauma-related symp toms. It is important to generate trauma awareness in agencies through education across services and among all staff members who have any direct or indirect contact with clients (including receptionists or intake and admission personnel who engage clients for the first time within the agency). Agencies can maintain a trauma-aware environment through ongoing staff training, continued su pervisory and administrative support, collabo rative. Individuals who have survived trauma vary widely in how they experience and express traumatic stress reactions. Traumatic stress reactions vary in severity; they are often meas ured by the level of impairment or distress that clients report and are determined by the mul tiple factors that characterize the trauma itself, individual history and characteristics, devel opmental factors, sociocultural attributes, and available resources. The characteristics of the trauma and the subsequent traumatic stress reactions can dramatically influence how indi viduals respond to the environment, relation ships, interventions, and treatment services, and those same characteristics can also shape the assumptions that clients/consumers make about their world. In essence, you will come to view traumatic stress reactions as normal reactions to abnormal situations. In embracing the belief that trauma-related reac tions are adaptive, you can begin relationships with clients from a hopeful, strengths-based stance that builds upon the belief that their responses to traumatic experiences reflect creativity, self-preservation, and determination. Some people have diffi 13 Trauma-Informed Care in Behavioral Health Services this will help build mutual and collaborative therapeutic relationships, help clients identify what has worked and has not worked in their attempts to deal with the aftermath of trauma from a nonjudgmental stance, and develop intervention and coping strategies that are more likely to fit their strengths and resources. This view of trauma prevents further retrau matization by not defining traumatic stress reactions as pathological or as symptoms of pathology. To more adequately understand trauma, you must also consider the contexts in which it occurred. Understanding trauma from this angle helps expand the focus beyond individu al characteristics and effects to a broader sys temic perspective that acknowledges the influences of social interactions, communities, governments, cultures, and so forth, while also examining the possible interactions among those various influences. In recent years, the social-ecological framework has been adopted in understanding trauma, in implementing health promotion and other prevention strategies, and in developing treat ment interventions (Centers for Disease Con trol and Prevention, 2009). The focus of this model is not only on nega tive attributes (risk factors) across each level, but also on positive ingredients (protective factors) that protect against or lessen the im pact of trauma. Refer to the "View Trauma Through a Sociocultural Lens" section later in this chap ter for more specific information highlighting the importance of culture in understanding and treating the effects of trauma. Trauma cannot be viewed narrowly; instead, it needs to be seen through a broader lens-a contextual lens integrating biopsychosocial, interpersonal, community, and societal (the degree of individualistic or collective cultural values) characteristics that are evident preced ing and during the trauma, in the immediate and sustained response to the event(s), and in the short- and long-term effects of the trau matic event(s), which may include housing availability, community response, adherence to 14 Part 1, Chapter 1-Trauma-Informed Care: A Sociocultural Perspective Exhibit 1. In addition, culture, de velopmental processes (including the devel opmental stage or characteristics of the individual and/or community), and the specific era when the trauma(s) occurred can signifi cantly influence how a trauma is perceived and processed, how an individual or community engages in help-seeking, and the degree of accessibility, acceptability, and availability of individual and community resources. Depending on the developmental stage and/or processes in play, children, adolescents, and adults will perceive, interpret, and cope with traumatic experiences differently. For example, a child may view a news story depicting a traumatic event on television and believe that the trauma is recurring every time they see the scene replayed. Similarly, the era in which one lives and the timing of the trauma can greatly influence an individual or community re sponse. Take, for example, a pregnant woman who is abusing drugs and is wary of receiving medical treatment after being beaten in a do mestic dispute. Even though a number of States have adopted poli cies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a crim inality standpoint. The innermost ring represents the individual and his or her biopsychosocial characteristics. The "Interpersonal" circle em bodies all immediate relationships including family, friends, peers, and others. The "Com munity/Organizational" band represents social support networks, workplaces, neighborhoods, and institutions that directly influence the individual and his/her relationships. The "So cietal" circle signifies the largest system-State and Federal policies and laws, such as eco nomic and healthcare policies, social norms, governmental systems, and political ideologies. The outermost ring, "Period of Time in His tory," reflects the significance of the period of time during which the event occurred; it influ ences each other level represented in the circle. The thicker arrows in the figure represent the key influences of culture, developmental characteristics, and the type and characteristics of the trauma. All told, the context of traumatic events can significantly influence both initial and sustained responses to trauma; treatment needs; selection of pre vention, intervention, and other treatment Exhibit 1. One evening, she was driving home in the rain when a drunk driver crossed into her lane and hit her head on. Marisol remained conscious as she waited to be freed from the car and was then transported to the hospital. Her recovery involved two surgeries and nearly 6 months of rehabilitation, including initial hospitalization and outpatient physical therapy. She described her friends and family as very supportive, saying that they often foresaw what she needed before she had to ask. She added that she had an incredible sense of gratitude for her em ployer and coworkers, who had taken turns visiting and driving her to appointments. Although she was able to return to work after 9 months, Marisol continued experiencing considerable distress about her inability to sleep well, which started just after the accident. Marisol describes repetitive dreams and memories of waiting to be transported to the hospital after the crash. Answering the following questions will help you see how the different levels of influence affect the impact and outcome of the traumatic event Marisol experienced, as well as her responses to that event: 1. What societal factors could play a role in the car crash itself and the outcomes for Marisol and the other driver Explore the influence of the period of time in history during which the scenario occurs-compare the possible outcomes for both Marisol and the other driver if the crash occurred 40 years ago versus in the present day. Minimize the Risk of Retraumatization or Replicating Prior Trauma Dynamics Trauma-informed treatment providers acknowledge that clients who have histories of trauma may be more likely to experience par ticular treatment procedures and practices as negative, reminiscent of specific characteristics of past trauma or abuse, or retraumatizing- feeling as if the past trauma is reoccurring or as if the treatment experience is as dangerous and unsafe as past traumas. Consider, for instance, a treatment program that serves meals including entrees that combine more than one food group. Your client enters this program and refuses to eat most of the time; he expresses anger toward dietary staff and claims that food choices are limited. However, a trauma-aware perspective might change your assumptions; consider that this client experienced neglect and abuse sur rounding food throughout childhood (his mother forced him to eat meals prepared by combining anything in the refrigerator and cooking them together). For agencies, staff members, and clients, these state ments present many difficulties and unwanted outcomes. For a client, such comments may replicate his or her earlier encounters with others (including family, friends, and previous behavioral health professionals) who had difficulty acknowledging or talking about traumatic experiences with him or her. Statements like these imply that recovery is not possible and provide no structured outlet to address memories of trauma or traumatic stress reactions. Nevertheless, determining how and when to address traumatic stress in behavioral health services can be a real dilemma, especially if there are no trauma-specific philosophical, programmatic, or procedural processes in place. For example, it is difficult to provide an appropriate forum for a client to address past traumas if no forethought has been given to developing interagency and intraagency collaborations for trauma-specific services. Therefore, it is important to maintain vigilance and an atti tude of curiosity with clients, inquiring about the concerns that they express and/or present in treatment. Remember that certain behaviors or emotional expressions can reflect what has happened to them in the past. Foremost, a trauma-informed approach begins with taking practical steps to reexamine treat ment strategies, program procedures, and or ganizational polices that could solicit distress or mirror common characteristics of traumatic experiences (loss of control, being trapped, or feeling disempowered). In sum, trauma-informed providers anticipate and respond to potential practices that may be perceived or experienced as retraumatizing to clients; they are able to forge new ways to re spond to specific situations that trigger a trauma-related response, and they can provide clients with alternative ways of engaging in a particularly problematic element of treatment. Create a Safe Environment the need to create a safe environment is not new to providers; it involves an agency-wide effort supported by effective policies and pro cedures. However, creating safety within a trauma-informed framework far exceeds the standard expectations of physical plant safety. Beyond anticipating that various environ mental stimuli within a program may generate strong emotions and reactions in a trauma survivor. Sometimes, providers From the first time you provide outpatient counseling to Mike, you explain that he can call an agency number that will put him in direct contact with someone who can provide further assistance or sup port if he has emotional difficulty after the session or after agency hours. Instead, Mike is directed by an operator to either use his local emergency room if he perceives his situation to be a crisis or to wait for someone on call to contact him. The inconsistency between what you told him in the session and what actually happens when he calls makes Mike feel unsafe and vulnerable. Honest and compassionate communication that conveys a sense of han dling the situation together generates safety. Counselors and other behav ioral health staff members, including peer support specialists, need to be able to count on the agency to be responsive to and maintain their safety within the environment as well. By incorporating an organizational ethos that recognizes the importance of practices that promote physical safety and emotional well being, behavioral health staff members may be more likely to seek support and supervision when needed and to comply with clinical and programmatic practices that minimize risks for themselves and their clients. Beyond an attitudinal promotion of safety, organizational leaders need to consider and create avenues of professional development and assistance that will give their staff the means to seek support and process distressing circumstances or events that occur within the agency or among their clientele, such as case Case Illustration: Jane consultation and supervision, formal or infor mal processes to debrief service providers about difficult clinical issues, and referral pro cesses for client psychological evaluations and employee assistance for staff. Organizational practices are only effective if supported by unswerving trauma awareness, training, and education among staff. In part, this is because people who have been exposed to trauma, whether once or repeatedly, are generally reluctant to revisit it.
They are close infection trichomoniasis buy generic cefadroxil 250 mg online, and the mode lies close to the middle of the data antimicrobial killing agent cheap cefadroxil 250mg with mastercard, so the data are symmetrical antimicrobial kitchen countertops purchase cefadroxil 250mg visa. Even though they are close antibiotic resistance threats in the united states 2013 buy discount cefadroxil 250 mg line, the mode lies to the left of the middle of the data antibiotic mouthwash prescription proven cefadroxil 250 mg, and there are many more instances of 87 than any other number yeast infection 250 mg cefadroxil with visa, so the data are skewed right. For batting average, higher values are better, so Fredo has a better batting average compared to his team. In the following histogram, the data values that fall on the right boundary are counted in the class interval, while values that fall on the left boundary are not counted (with the exception of the first interval where values on both boundaries are included). Compare the graph for the Singles with the new graph for the Couples: this content is available for free at cnx. Possible answers include: Although the width of the class intervals for couples is double that of the class intervals for singles, the graphs are more similar than they are different. The range of spending for couples is approximately double the range for individuals. Each plot is skewed to the right, so the ages of the top 50% of buyers are more variable than the ages of the lower 50%. Based on the information in the table, graph (a) most closely represents the data. It is often necessary to "guess" about the outcome of an event in order to make a decision. The probability is equal to those who have change and rode a bus divided by those who rode a bus. Three ways to represent a sample space are: to list the possible outcomes, to create a tree diagram, or to create a Venn diagram. Probabilities are between zero and one, inclusive (that is, zero and one and all numbers between these values). Equally likely means that each outcome of an experiment occurs with equal probability. For example, if you toss a fair, six-sided die, each face (1, 2, 3, 4, 5, or 6) is as likely to occur as any other face. If you randomly guess the answer to a true/false question on an exam, you are equally likely to select a correct answer or an incorrect answer. Let event E = rolling a number that 6 surprised if your observed results did not match the probability. If you were to roll the die a very large number of times, you 6 2 as the number of the long-term relative frequency of obtaining this result would approach the theoretical probability of 6 repetitions grows larger and larger. Even though the outcomes do not happen according to any set pattern or this content is available for free at cnx. Gambling casinos make a lot of money depending on outcomes from rolling dice, so casino dice are made differently to eliminate bias. Later we will learn techniques to use to work with probabilities for events that are not equally likely. P(A B) is the probability that event A will occur given that the event B has already occurred. To calculate P(A B), we count the number of outcomes 2 or 3 in the sample space B = {2, 4, 6}. Understanding the wording is the first very important step in solving probability problems. Suppose you know that the picked cards are Q of spades, K of hearts, and J of spades. If it is not known whether A and B are mutually exclusive, assume they are not until you can show otherwise. Suppose that of those women who develop breast cancer, a test is negative 2% of the time. If he goes out the second door, the probability he 4 1 and the probability she does not catch Muddy is 1. Muddy will choose any of the three doors so the probability of choosing each door is 3 4 Caught or Not Caught Not Caught Total gets caught by Alissa is 1 and the probability he is not caught is 3. The probability that Alissa catches Muddy 5 5 Door One 1 15 4 15 Door Two 1 12 3 12 Door Three 1 6 1 6 Total 1 Table 3. Caught or Not Caught Door One 1 15 Door Two 1 12 Door Three 1 6 Total 19 60 Table 3. Find the probability that a randomly chosen individual from this group is Obese and Tall. Tree diagrams and Venn diagrams are two tools that can be used to visualize and solve conditional probabilities. It consists of "branches" that are labeled with either frequencies or probabilities. The sample space has been reduced to those outcomes that already have a blue on the first draw. A family comes in and randomly selects two kittens (without replacement) for adoption. In the Venn Diagram, describe the area in the rectangle but outside both the circle and the oval using a complete sentence. The second time through, after picking the first M&M, do not replace it before picking the second one. Convert P(no yellows) to decimal format for both Theoretical "With Replacement" and for Empirical "With Replacement". Event a subset of the set of all outcomes of an experiment; the set of all outcomes of an experiment is called a sample space and is usually denoted by S. It can contain one outcome, two outcomes, no outcomes (empty subset), the entire sample space, and the like. Events are subsets of the sample space, and they are assigned a probability that is a number between zero and one, inclusive. The events A and B are mutually exclusive events when they do not have any outcomes in common. Contingency tables help display data and are particularly useful when calculating probabilites that have multiple dependent variables. The probability that a randomly selected student is a male student with short hair. A jar of 150 jelly beans contains 22 red jelly beans, 38 yellow, 20 green, 28 purple, 26 blue, and the rest are orange. Let B = the event of getting a blue jelly bean Let G = the event of getting a green jelly bean. Write the symbols for the probability that a player is an outfielder or is a great hitter. Write the symbols for the probability that a player is a great hitter, given that the player is an infielder. Write the symbols for the probability that a player is an infielder or is not a great hitter. The probability that a man has at least one false positive test result (meaning the test comes back for cancer when the man does not have it) is 0. Of the people smoking at most ten cigarettes per day, there were 9,886 African Americans, 2,745 Native Hawaiians, 12,831 Latinos, 8,378 Japanese Americans, and 7,650 Whites. Of the people smoking 21 to 30 cigarettes per day, there were 1,671 African Americans, 1,419 Native Hawaiians, 1,406 Latinos, 4,715 Japanese Americans, and 6,062 Whites. What proportion in the poll disapproved of Mayor Ford, according to the results from late 2011 What is the probability that a person supported Mayor Ford, based on the data collected in early 2011 The casino game, roulette, allows the gambler to bet on the probability of a ball, which spins in the roulette wheel, landing on a particular color, number, or range of numbers. At a college, 72% of courses have final exams and 46% of courses require research papers. A college finds that 10% of students have taken a distance learning class and that 40% of students are part time students. Let D = event that a student takes a distance learning class and E = event that a student is a part time student a. What is the probability that a randomly selected senator is a Republican or is up for reelection in November 2014 When the Euro coin was introduced in 2002, two math professors had their statistics students test whether the Belgian one Euro coin was a fair coin. Use the tree to find the probability of obtaining exactly one head in two tosses of the coin. Rider, David, "Ford support plummeting, poll suggests," the Star, September 14, 2011. Yes, they are independent because the first card is placed back in the bag before the second card is drawn; the composition of cards in the bag remains the same from draw one to draw two. P(>64 F) is the percentage of female drivers who are 65 or older and P(>64 and F) is the percentage of drivers who are female and 65 or older. Small companies might be interested in the number of long-distance phone calls their employees make during the peak time of the day. If X is a random variable, then X is written in words, and x is given as a number. After all members of the class have completed the experiment (tossed a coin ten times and counted the number of heads), fill in Table 4. She attends classes three days a week 80% of the time, two days 15% of the time, one day 4% of the time, and no days 1% of the time. This "long-term average" is known as the mean or expected value of the this content is available for free at cnx. The fourth column of this table will provide the values you need to calculate the standard deviation. To do this problem, set up an expected value table for the amount of money you can profit. Since you are interested in your profit (or loss), the values of x are 100,000 dollars and -2 dollars. The probability of choosing one correct number is 1 10 because there are ten numbers. To calculate the standard deviation of a probability distribution, find each deviation from its expected value, square it, multiply it by its probability, add the products, and take the square root. For some probability distributions, there are short-cut formulas for calculating and. The sample space has 36 outcomes: (1, 1) (1, 2) (1, 3) (1, 4) (1, 5) (1, 6) (2, 1) (2, 2) (2, 3) (2, 4) (2, 5) (2, 6) (3, 1) (3, 2) (3, 3) (3, 4) (3, 5) (3, 6) (4, 1) (4, 2) (4, 3) (4, 4) (4, 5) (4, 6) (5, 1) (5, 2) (5, 3) (5, 4) (5, 5) (5, 6) (6, 1) (6, 2) (6, 3) (6, 4) (6, 5) (6, 6) Table 4. If you make this bet many times under the same conditions, your long term outcome will be an average loss of $5. The letter p denotes the probability of a success on one trial, and q denotes the probability of a failure on one trial. Another way of saying this is that for each individual trial, the probability, p, of a success and probability, q, of a failure remain the same. Suppose Joe always guesses correctly on any statistics true-false question with probability p = 0. This means that for every true-false statistics question Joe answers, his probability of success (p = 0. The mean, and variance, 2, for the binomial probability distribution are = np and 2 = npq. Any experiment that has characteristics two and three and where n = 1 is called a Bernoulli Trial (named after Jacob Bernoulli who, in the late 1600s, studied them extensively). This implies that, for any given term, 70% of the students stay in the class for the entire term. The probability that you win any game is 55%, and the probability that you lose is 45%. Here, if you define X as the number of wins, then X takes on the values 0, 1, 2, 3. The probability that the dolphin successfully performs the trick is 35%, and the probability that the dolphin does not successfully perform the trick is 65%. Out of 20 attempts, you want to find the probability that the dolphin succeeds 12 times. In a statistics class of 50 students, what is the probability that at least 40 this content is available for free at cnx. Failure is defined as a student who does not complete his or her homework on time. Let X = the number of workers who have a high school diploma but do not pursue any further education. The syntax for the instructions are as follows: To calculate (x = value): binompdf(n, p, number) if "number" is left out, the result is the binomial probability table. To calculate P(x value): binomcdf(n, p, number) if "number" is left out, the result is the cumulative binomial probability table. The probability of a student on the second draw is 5, when the first draw selects a student.
The pain eases but now she notices that she has difficulty standing and walking (her legs feel weak and wobbly antimicrobial yahoo generic cefadroxil 250 mg with visa, and she has been incontinent of urine) antibiotic bronchitis order cefadroxil 250mg free shipping. A Collapsed vertebral body secondary to occult myeloma B Central disc prolapse C Transverse myelitis D Dissecting aneurysm blocking off the blood supply to the spinal cord antibiotic 6 days purchase cefadroxil 250 mg without prescription. A 70-year-old man who has smoked all his life now presents feeling unwell and with weight loss yeast infection 9 weeks pregnant generic 250 mg cefadroxil visa. Chest X-ray is normal but plain X-ray of the spine shows several collapsed vertebrae virus 2014 250 mg cefadroxil with amex. A Radiotherapy B Chemotherapy C Harrington rods to the spine D Steroids E Embolisation of tumours A B C D E of the foot and the lateral side of the calf infection game cheats buy cefadroxil 250mg lowest price. Prolapse of the L5/S1 disc pressing on the S1 nerve root Prolapse of the L5/S1 disc pressing on the L5 nerve root Facet joint arthritis Infective discitis Neuroma of a nerve root. D Spinal claudication progresses in less than 50 per cent; vascular progresses in more than 50 per cent of cases. A 65-year-old man who has lived all his life in Britain presents with severe and constant back pain at L3, which does not radiate down the legs. X-rays show destruction of the disc space at L2/L3 with invasion of the destruction into the adjacent vertebral bodies. A Tumour cells (metastases) B Primary chondrosarcoma cells C Mycobacterium tuberculosis D Escherichia coli E Sterile avascular necrosis. A Prolapsed intervertebral disc B Spondylolisthesis C Collapsed vertebra D Muscle strain. A 40-year-old labourer presents with backache radiating down the left leg to the foot. His left foot drags and on examination he has weakness in extensor hallucis longus. There is also diminished sensation over the dorsum 234 (b) What test can be used to measure the severity of the problem Answers: Multiple choice questions Epidemiology, anatomy and physiology of back pain 1. B, C, D the chance of someone having back pain at some time in their life is between 60 and 80 per cent, but over 80 per cent of episodes settle spontaneously within 6 weeks of onset without the need for any aggressive investigation or treatment. The blood supply to the spinal cord is mainly by the radicular arteries, but the lower spinal cord is supplied by the anterior spinal artery which is mainly filled from the radicular artery of Adamkiewicz. It is unlikely to be occult malignancy or an aneurysm as the patient is too young and transverse myelitis is not usually painful. Absence of pain does not exclude a central disc, and unilateral signs are usually related to a single nerve root trapped in the lateral foramen (a lateral protrusion). This includes trauma, but also includes patients under 20 or over 55, those with a history of cancer, and anyone with a history of night pain, fever and/or weight loss. However, the radiation dose needed to search for lesions of multiple myeloma using X-rays would be large and bone scintigraphy would be a better screening method. Osteoporosis cannot be diagnosed reliably on plain X-ray or by scintigraphy, and so bone densitometry should be used. Most tumours in the spine are secondaries (98 per cent) and the commonest secondaries are breast (20 per cent), lung (15 per cent), prostate, renal, gastrointestinal and thyroid (all under 10 per cent), so there is little point in starting with lung, bowel or kidney tests until more information is available. Steroids might help the pain and embolisation should probably only be attempted if surgery is planned to decompress the spine or remove the tumour. B the fact that the pain radiates down to the foot suggests that it is radicular rather than referred, so facet joint arthritis and discitis are unlikely to be the cause. The motor supply to extensor hallucis longus is pure L5, and the dermatomal distribution of L5 is the dorsum of the foot and lateral side of the calf. B, C, D, E In both spinal and vascular claudication, pain is initiated by exercise, but as a general rule vascular claudicants get pain going uphill (when the leg muscles require more oxygen) while spinal claudicants get worse pain going downhill (when the spinal canal narrows in extension). Spinal claudication only progresses in around 20 per cent of cases and if it does, spinal decompression can offer significant relief of symptoms. A young, fit person would be most unlikely to collapse a vertebra without very major trauma. He or she could have prolapsed a disc but then there would likely be pain radiating down the leg (sciatica). This is a measure of the maximum angle of the curvature of the spine on an anteroposterior X-ray. Obviously the more severe the deformity when the patient first presents, the more severe the deformity is likely to be when growth ends and the deformity stops progressing. Self-esteem may indeed be damaged but there is no validated measure in these cases. A Physiotherapy and re-education B Physiotherapy first but if that fails then surgical repair of the Bankart lesion C Physiotherapy first but if that fails then reefing of the capsule. A Supraspinatus B Teres major C Teres minor D Infraspinatus E Pectoralis minor F Subscapularis. A young woman notices that her shoulder comes out of joint sometimes when she is asleep. A Physiotherapy and re-education B Physiotherapy first but if that fails then surgical repair of the Bankart lesion Rheumatoid arthritis 6. Which of the following deformities are seen in a patient with chronic and severe rheumatoid arthritis However, if the arm is lifted by the examiner, the pain is much less severe, and once the arm is right up, it is no longer painful. However, when the examiner lifts the arm up and back he becomes very apprehensive and asks them to stop. She is able to rotate the shoulder externally without much pain, but other movements are painful, especially active ones. Which of the following treatments give reliable results in rheumatoid arthritis of the hand Elbow injury 1 A patient attends with pain over the lateral side of the elbow following a weekend redecorating the house. Hand grip Pinch Power Hook Key Chuck Choose and match the correct type of grip with each of the following activities: 1 Holding a pen 2 Holding a hammer 3 Picking up loose change 4 Carrying a suitcase 5 Holding a credit card as you put it into a cash machine 4. Hand injury A B C D E F Rupture of the extensor hood Malunion of an oblique fracture of the proximal phalanx Pilonidal sinus Flexor tendon sheath infection Disjunction of the palmar arch on the ulnar side Nerve damage Choose and match the correct diagnosis with each of the following scenarios: 1 A patient complains that when they make a fist one finger crosses and tangles with the rest. Even passive flexion is painful, and pressing on the palmar side of the finger is very sore. A, C, D, F There are four muscles which insert into the rotator cuff and control it: supraspinatus, infraspinatus, subscapularis and teres minor. A, E Shoulder replacement gives reliable pain relief but often does not increase shoulder range of movement. Indeed, the pain relief provided by a glenohumeral arthrodesis often results in a better range of movement than a replacement, as the full range of movement available in the scapulothoracic joint can now be used. The absence of the rotator cuff makes shoulder replacement much less reliable unless the cuff can be repaired at the same time (which is unlikely). If the glenoid is well preserved, a partial (hemi) joint replacement will also give good results. If the dislocation does not settle and recurs, then surgery to repair the Bankart lesion and reefing of the capsule will provide good results in over 90 per cent of cases. A, B, D, E, H, J, K There are a large number of deformities associated with rheumatoid arthritis. Prosthetic replacement of the wrist is not currently proving as valuable in terms of pain relief and function as arthrodesis. Tendon repairs tend not to work well but tendon transfer using healthy tendons gives better results. It is the pattern of these three, the age and gender of the patient, and the cause of the onset of symptoms (traumatic or gradual) which give a clue to the diagnosis in most of the conditions. In the first instance, the treatment is physiotherapy to build the strength of the muscles around the shoulder. Repeated dislocations will need a surgical repair of the labrum and of the capsule. The woman who has fallen onto her shoulder (Scenario 7) will have suffered a fracture through osteoporotic bone. If, however, it is intra-articular or grossly displaced (so that the blood supply to the humeral head is damaged), a hemiarthroplasty may be the only option. If the intra-articular fracture is left (as used to happen), then traumatic osteoarthritis is inevitable in the years to come. This will present with gradual onset of pain, stiffness and weakness, and the best treatment is probably a shoulder replacement. Arthritis in the shoulder also develops in patients with rheumatoid arthritis, and they too respond well to a shoulder replacement. The patient presenting with a painless but weak shoulder (Scenario 2) where the problem has developed over the years has almost certainly got a massive tear of the rotator cuff. The cuff has a poor blood supply and so any attempt at repair is doomed to failure. It may therefore be best to simply explain the diagnosis and commiserate with them. Once again, physiotherapy and re-education should be sufficient as the child will grow out of it if they stop doing it. The presentation of severe pain and stiffness after minor trauma (Scenario 3) is characteristic of a frozen shoulder. This is very slow to resolve and it is doubtful whether anything helps reduce the months of pain and stiffness, but most clinicians would offer analgesia and gentle physiotherapy. Severe pain and stiffness developing rapidly without any trauma at all (Scenario 3) could be a frozen shoulder but could also be calcifying tendinitis of the supraspinatus tendon. Frozen shoulder produces global pain and loss of movement, including pain on external rotation. On X-ray a calcific cloud will be visible in the supraspinatus tendon between the acromion and the humeral head. Painful arc syndrome is the finding that the patient cannot actively abduct their arm from their side beyond a certain point (the start of the painful arc) because it becomes very painful (Scenario 1). If, however, examiner lifts the arm for the patient through this painful arc, they are quite suddenly able to abduct the final bit without much pain. This condition can be diagnosed with an injection of local anaesthetic into the impinging area, and some attempt treatment with a steroid injection. However, trimming of the downward-pointing tip of the acromion (subacromial decompression) should relieve the impingement and therefore the pain. Elbow injury (a) 1A, 2B, 3C, 4G, 5E, 6C, 7D, 8F Tennis elbow does not only develop after playing tennis but can start after any heavy activity. In rheumatoid arthritis, the elbow is frequently attacked first in the radiohumeral joint. Sudden onset of locking in the elbow without a history of trauma is the typical presentation of osteochondritis dissecans (a fragment of the articular surface breaking off spontaneously). Fractures into the elbow will go on to aggressive traumatic arthritis if it is not possible to get anatomical reduction of the joint surfaces. A red and hot lump over the extensor surface of the elbow is likely to be olecranon bursitis, whereas a hot and painful elbow joint with a low-grade fever is more likely to be infection, and in the elbow tuberculosis must be in the differential diagnosis. Radiohumeral pain can be diagnosed by injecting local anaesthetic into this joint and demonstrating pain relief. Plain X-ray is the most useful diagnostic test in rheumatoid and osteoarthritis as well as osteochondritis dissecans. Arthritis in the elbow can lead to irritation and compression of the ulnar nerve where it passes behind the elbow joint. If a patient with rheumatoid arthritis has isolated radiohumeral arthritis, as demonstrated by pain on pronation and supination relieved by injection of local anaesthetic, then synovectomy and excision of the radial head should give good pain relief without creating too much instability in the elbow joint. However, if the whole elbow joint is involved, a total elbow replacement is indicated. If the patient performs heavy labour, an arthrodesis will last better than an elbow replacement. Osteochondritis dissecans can be managed by arthroscopic removal of the loose fragment in the first instance. Patients with signs of ulnar nerve entrapment will need release and transposition of the ulnar nerve. A Artery of the ligamentum teres B Retinacular branches of the medial circumflex femoral artery C Capsular branches of superior gluteal artery. Which of the following structures are involved in static stability of the hip joint Which of the following structures are involved in supporting the pelvis when standing on one leg A Capsule B Labrum C Gemelli D Pectineus E Iliopsoas F Ligamentum teres G Anterior inferior iliac spine H Cup and socket shape of hip joint I Abductor muscles J Hamstrings K Gluteals. A Subchondral sclerosis B Multiple microfractures C Subchondral cysts D Coarsening of the trabecular pattern E Narrowing of the joint space F Osteophyte formation G Periarticular osteoporosis. If you had to explain to a patient the complications of total hip replacement, which of the following would you mention A Infection B Deep vein thrombosis C Renal failure D Urinary tract infection E Nerve damage F Synergistic gangrene G Chest infection H Stroke I Dislocation J Fracture K Severe bleeding requiring transfusion L Death from any cause less than 1 per cent M Leg length inequality more than 10 cm N Compartment syndrome. A Biceps femoris B Anterior cruciate ligament C Posterior cruciate ligament 246 Sartorius Gracilis Semitendinosus Medial meniscus Lateral meniscus Quadriceps femoris Adductor longus. Management of hip conditions A B C D E F Surface hip replacement Hemiarthroplasty Conventional stemmed hip replacement Core graft to hip Arthrodesis Osteotomy Choose and match the correct treatment with each of the following scenarios: 1 A patient presents with reduction of movement of the hip. Hip replacement A B C D Aseptic loosening Dislocation Periprosthetic fracture Infected implant Choose and match the correct diagnosis with each of the following scenarios: 1 On getting out of bed, a patient who had a hip replacement 4 days previously felt a severe pain in his new hip. Management of knee conditions A B C D Total knee replacement High tibial osteotomy Unicompartmental knee replacement Arthrodesis of the knee Choose and match the correct treatment with each of the following scenarios: 1 A 20-year-old patient has medial compartment osteoarthritis after an intra-articular fracture.
All the clinical features result from raised intra-abdominal pressure treatment for uti in female dog cefadroxil 250 mg otc, which compresses the individual organs bacteria helicobacter pylori espaol discount 250mg cefadroxil amex, thereby causing deterioration of their individual functions antibiotics vs probiotics order 250 mg cefadroxil with mastercard. Renal failure infection from pedicure purchase 250 mg cefadroxil with visa, decreased cardiac output from reduction in preload and increase in afterload iv antibiotics for sinus infection purchase cefadroxil 250 mg without a prescription, respiratory embarrassment from raising of the diaphragm and reduction in visceral perfusion account for this complication antibiotics human bite 250mg cefadroxil fast delivery. Measurement of intra-abdominal pressure by measuring the intravesical pressure through the indwelling catheter will help in making a diagnosis. An intra-abdominal pressure of more than 25 mmHg is sinister and the patient requires immediate abdominal decompression. Some surgeons following major surgery after severe abdominal trauma would leave the abdomen open, covered with a plastic mesh. This nature of injury should alert one to the possibility of a diaphragmatic injury. On the chest X-ray, the tip of the nasogastric tube next to the heart confirms the injury. The abdominal route is preferred so that injury to abdominal organs is excluded and repaired if necessary. Every time the patient passes urine, some of it is saved in a transparent jar and the time of passing urine is noted. In selected cases, if the haematuria does not improve while the patient is still stable, there is a place for selective renal angiogram with a view to renal artery embolisation. Haematuria following minor trauma should alert the surgeon to the possibility of injury to a pathological kidney, such as a congenital hydronephrosis or horseshoe kidney. If the patient remains stable, liver injuries are treated conservatively, as most of them are. In very severe injuries, after packing the damaged liver, the patient should be transferred to a tertiary hepatobiliary unit. She has fractured left lower ribs and referred pain to her shoulder tip due to diaphragmatic irritation from blood under the left dome from a ruptured spleen. Otherwise a laparotomy is done at which a splenectomy or splenorrhaphy or splenic preservation by placing it in a mesh bag is attempted. The commonest cause of acute pancreatitis in a child is from blunt trauma to the abdomen from a cycle handlebar injury. At the time she suffered from traumatic acute pancreatitis which obviously was not clinically bad enough to seek hospital help. Over the ensuing 10 days she has developed a mass in the epigastrium typical of a pseudocyst. This should be confirmed by ultrasound scan, which would show a cyst behind the stomach. Which of the following important injuries are commonly missed, because some X-rays may look normal D Relative stability means that some movement at the fracture site is going to occur. Which of the following statements regarding the Gustillo and Anderson classification of fractures is true G Absolute stability should not be attempted if, in achieving it, the blood supply to the bone will be compromised. Since then, every time he turns with his weight on that leg it is liable to give way under him, and also locks on occasions. A B C D E F G H I A B C D Rotated Shortened Translated Angulated Segmental Wedge Transverse Oblique Spiral 3. Types of fracture union Malunion Non-union Infected non-union Delayed union Choose and match the correct diagnosis with each of the scenarios given below: 1 A patient breaks his femur. It is treated in traction and then with a plaster brace, because he refuses surgery. Over a period of 8 weeks the femur bends into 15 of varus, producing a prominent lump on the outside of the thigh. It is fixed with a blade plate but at review 3 months after the accident, the fracture is still visible on X-ray. At 6 weeks, the plaster is removed but it is clear that the fracture is still mobile, although some callus is visible on X-ray. C, D, G, H, I All the conditions which are commonly missed are rare and also difficult to diagnose. Perilunate dislocations are much rarer than a scaphoid fracture and are very difficult to see on X-ray unless you know how to look for the change in relationship of the bones of the carpus Compartment syndrome is very rare and has no reliable investigation for proving or excluding its presence. Slipped upper femoral epiphysis is like a posterior dislocation of the shoulder and looks fairly normal on an X-ray. It can be difficult to see on X-ray and yet can have dire consequences, as the fracture may divide the blood supply from the talar head and lead to avascular necrosis of the talar body. Although it is normally associated with a closed fracture, it can result from any blunt trauma and the bone does not need to be fractured. It occurs most commonly in the deep flexor compartment of the calf and in the flexor compartment of the forearm but can occur anywhere that the muscles are held in an inextensible fascial sac. It results from swelling (usually bruising) increasing the pressure inside an inextensible fascial compartment. The thin-walled veins containing blood at low pressure collapse in on themselves and no longer drain blood from the compartment, but the high-pressure, stiff-walled arteries continue to pump blood into the compartment. A vicious cycle is therefore set up where the pressure in the compartment continues to rise, and this prevents the blood from draining out. The distal pulses and even sensation may be unimpaired, because the arteries still pump blood, and if the distal nerve does not pass through that compartment it will be unaffected. If a compartment syndrome develops in the deep posterior compartment of the leg then neither the anterior nor the posterior tibial nerve will be affected and so sensation in the foot will be grossly normal. Once the pressure in the affected compartment has reached mean systolic pressure, all circulation ceases because blood cannot enter or leave the capillary bed of the compartment and ischaemia begins. It is very difficult to measure the intracompartmental pressure and so the diagnosis is a clinical one. The patient experiences pain out of all proportion to the injury, and if the muscles are stretched (passive extension), the patient experiences extreme pain. The pressure in the compartment needs to be released within hours if permanent damage is to be avoided. The initial treatment is to release any external factor which might be causing compression, such as a plaster or bandage. If there is not immediate relief of symptoms then the compartments involved need to be opened surgically (fasciotomy) and then left open until the swelling has reduced. A, D, E the Gustillo and Anderson classification is designed for open fractures and applies only to the state of the soft tissues. It takes little account of the length of any lacerations, as its primary concern is the energy that has been imparted to the soft tissues and hence their disruption. It does not take any account of the body part involved, despite the fact that blood supply and soft-tissue cover vary greatly in different parts of the body. The metaphysis is the weakest side and the blood supply enters from the epiphysis, so this fracture does not damage the growth potential of the plate. This fracture is by far the most common and luckily has a good prognosis as, once again, it is tracking along the safe (metaphyseal) side of the epiphyseal plate. If it creates a step in the joint, there is a significant risk of the onset of premature traumatic osteoarthritis, so this fracture needs careful management. If there is any displacement then, when healing occurs, a bar of bone bridges across the epiphyseal plate from the metaphysis to the epiphysis. The first of these is reduction, or putting the fragments back together so that the shape and alignment of the bone are correct. If the fracture is undisplaced or the displacement does not matter, the reduction is not needed. This may be because the fracture is in multiple fragments or there may even be fragments missing. Absolute stability is only possible when the bone fragments can be reduced perfectly and then compressed together. It leads to primary bone healing, which is in effect the same as bone remodelling. The risk of attempting to obtain absolute bone stability in a complex fracture is that the fragments of bone may get stripped from their bone supply and so fail to unite. C, E Plaster of Paris allows a fracture to be stabilised (relatively) without the need for open surgery. However, if a closed plaster is put on, swelling in the early stages may lead to circulatory compromise of the limb. The alternative, non-operative way of treating a fracture is to apply traction and use the tension created in the soft tissues to stabilise it. This stability is relative and so secondary bone healing (callus formation) occurs. In these circumstances the patient can mobilise, leave hospital and return to many activities of daily living long before the fracture has united. They should therefore not be used in children in case they damage the growth plate. External fixators can bridge across damaged tissue and so are especially useful when there is soft-tissue damage or loss and the use of a plate or nail would give an unacceptable risk of infection. Arthroplasty is an important tool in the armamentarium of a trauma surgeon for giving quick recovery in a fracture which has damaged a joint beyond the possibility of reconstruction (through loss of blood supply to fragments etc. Imaging in trauma 1D Sudden onset of pain in the calf during a game of squash may be a rupture of the Achilles tendon. Soft tissues are usually best visualised with ultrasound, especially if dynamic imaging is needed. Fluoroscopy (image intensifier) is the best way of achieving this while keeping the radiation dose to a minimum. If it is seen in the femur of young children, it is commonly the result of non-accidental injury. It, too, is unstable and will slide out of position if weight is taken on this broken bone. This injury occurs in the tibia of footballers when another player lands on their leg. It can be a relatively stable fracture, if a perfect reduction is obtained, as axial loading merely compresses it. This is classically the injury seen in a pedestrian hit on the tibia by the bumper of a car. The central fragments can sometimes lose their blood supply, so non-union may be a problem. Once again it is likely to need reduction before fixation, otherwise a malunion will result. If this is not reduced, the fracture will still heal, but the limb will heal much shorter than before. Normally this is accompanied by a spiral fracture, in which case the fragments are usually displaced and shortened. On X-ray the diameter of the cortices may not match as the bones are often oval in cross-section. Types of fracture union 1A If a fracture heals in a poor position, this is called malunion. This femur has shifted into varus, producing an unsightly bump on the lateral side. The deformity is likely to interfere with the mechanics of the knee and the ankle. It may be that the fracture site has completely lost its blood supply, but something more than simply re-fixing the fracture will be needed. This could be a result of rapid bone healing, but the X-ray shows no sign of union. If the result is not union in a perfect position, this does not matter too much in the humerus, as it does not show, or affect function. The fixator is cumbersome and the tracks of the pins or wires used to fix the bones to the fixator can become infected. The anatomical fix obtainable with plates and screws is ideal for forearm fractures where a perfect reduction is needed if full pronation and supination are to be achieved. Optimal fixation requires careful planning, and infection is a risk even in the best-equipped and organised operating theatre. It is a safe and cheap method of stabilising a fracture but carries the complication that, if there is significant swelling within a closed plaster, serious ischaemia may result.
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