By C. Milok. National American University. 2018.
Specifically cheap clindamycin online amex, consistent with previous findings best buy for clindamycin, interviewees indicated that the power relations that operate within the therapeutic alliance influenced their adherence order clindamycin amex. They tended to contrast a collaborative alliance, whereby treatment decisions were shared, with an authoritative alliance, whereby interviewees perceived their prescribers to have control over their treatment regimens. Additionally, interviewees indicated that prescribers’ interest in their experiences (as reflected through in-depth questioning) and their knowledge of relevant background information were important to them. Most importantly, interviewees overwhelmingly reported that the degree to which their prescribers tailored their medication regimens to their individual circumstances, including symptom fluctuations, stressful situations and lifestyle factors, influenced their adherence. Extracts that relate to these aspects of the therapeutic alliance are presented below. Whilst collaboration is considered a cornerstone of a positive therapeutic alliance, the degree to which collaboration actually takes place in clinical practice has been challenged by some research. Similarly, in their qualitative interview studies involving people with psychiatric illnesses including schizophrenia, Sharifet al. Interviewees in the present study consistently highlighted the importance of collaboration. Their accounts also frequently indicated that a collaborative therapeutic alliance does not reflect their actual experiences. In the following extract, Travis highlights the importance of the therapeutic alliance to consumers’ future outcomes and describes what a “good” relationship with the treating prescriber looks like: Travis, 19/02/2009 T: You’ve gotta have a good relationship with your psychiatrist. L: Yeah and you said you’ve been able to negotiate your medication with her as well. I mean, there’s been times when they’ve said, look, we want it down a bit more and I’ve said, no, I’m not ready, and they’ve said, fine. It has to be reasonable but they have to, you know, at least have explained to them why, you know. Travis constructs a “good relationship” with the treating psychiatrist as encompassing listening (“you wanna be able to feel heard”) and understanding of the rationale for prescribing medication ( “have explained to them, why, you know”) as well as the treatment direction (“what needs to be done”). Prompted by the questioning, Travis also provides an example which illustrates how he has been able to negotiate his medication schedule in the past and assert control over his treatment by declining his psychiatrist’s proposal to lower his dosage. Travis indicates that it is essential that consumers have some control over their treatment (“they need to be a part of it…need to have some say”) considering that they will be consuming the medication (“It’s themselves that are going through it”). Whilst he does not directly link these elements of the therapeutic alliance to his adherence, he could be seen to be referring partly to the consequences of non-adherence 214 when highlighting the negative outcomes associated with a poor treatment alliance (“otherwise, you’re not gonna get anywhere”). In the following extract, Amy also indicates that some of the components identified by Travis represent important aspects of the therapeutic alliance, associated with adherence outcomes. Amy provides more in depth detail about what an “authoritative” therapeutic alliance might look like as well, based on personal experiences: Amy, 10/02/2009 A: I think negotiation uh, where the client or patient feels like they’ve not only had a say but, not taking control but has an equal say of at least their opinion is being equally considered. Yeah, uh it’s not, (inaudible) or parent-like, it should be negotiated like you’re a colleague or a friend that you met at work or something but not an unprofessional friend... That kind of, familiarity and once you’ve developed a good working rapport with your psychiatrist, I think it’s important for your psychiatrist to build a good rapport or your occupational therapist or any treating health professional, develop a good rapport with their, uh, patient. The only thing you have to be wary of is developing too good of a rapport that um the patient can sometimes get transference from if you have (inaudible). Basically having a collaborative relationship where you can discuss things, it’s an open forum, as opposed to being I guess quite punitive and taking a more um- A: Yeah see a lot of doctors act just like parents, parent, naughty child attitude or starts um, regarding compliance with their patients, I think they’d be far more successful if, I mean I’ve-, sometimes you do need a firm 215 hand but not a heavy hand, like it is often practised today if patients aren’t compliant, I can only speak for myself in that uh, I’m more likely to be compliant if the-, I mean sometimes you do need to get tough on me, I admit, and uh, my brother and sister, in particular my brother being the disciplinarian has driven me to tears at points because I’ve been ridiculous and I’ve needed a big kick up the bum and he does that for me but he’s equally loving and caring as well. Rather than being authoritative I think the patient needs to feel like they’ve had an equal say and that’s being equally valued uh, as strongly as they feel about their opinion and like, it’s been at least considered by the psychiatrist or treating medical health professional. Most of all you need to feel heard and that your opinion is being considered and maybe even counted in moderation with their medical health care. Amy highlights several important components of a therapeutic alliance which she implies are associated with her adherence (“I’m more likely to be compliant if…)”. Specifically, Amy emphasizes the importance of “collaboration” with her prescriber, comprising “negotiation” whereby she feels that she has some “control” or an “equal say” and that her “opinion is being equally considered”. She additionally highlights the importance of consumers establishing a “good rapport” with their prescriber, whilst acknowledging the necessity of prescribers to be professional in their interactions with consumers. Amy contrasts a collaborative therapeutic alliance with one where there is a power imbalance, which she likens to a 216 “parent, naughty kid” dynamic to illustrate. Amy constructs the prevalence of “authoritative”, “punitive” prescribers as common (“a lot of doctors act just like parents”) and particularly evident when consumers are non- adherent (“a heavy hand, like it is often practiced today if patients aren’t compliant”). Amy could be seen to suggest that the power imbalance results from the consumer being non-adherent in the latter quote, whereas the alternative perspective is that consumers become non-adherent in response to an authoritative prescriber. She supports the need for prescribers to occasionally be “firm” with her to encourage adherence but indicates that such an approach is most effective when counterbalanced with “caring”. Below, Anna also highlights the importance of the consumer being “listened to” and contrasts this with her experience during a hospitalisation of being administered an exceptionally high dosage of medication which impeded her ability to contribute to treatment decisions (“And not have them so bombed so that they can make um decisions”): Anna, 18/02/2009 A: Hmm, I think too that the, the person needs to be listened to. That- 217 L: It’s like giving the client some control over their own treatment, or giving them- A: Could yeah, like give them like a small, a small dosage and maybe nice medications just to get them-, build them up slowly to a level rather than bombarding them with medication and you’re just left to it. Anna represents her experience of being over-medicated as compromising the capacity for collaboration in the therapeutic alliance.
Papillary thyroid carcinomas are highly curable discount clindamycin 150mg without a prescription, spreading locally and into nearby lymph nodes before becoming blood-borne and metastatic to lung order genuine clindamycin online, bone purchase clindamycin 150mg overnight delivery, or other sites. Residual disease or metastases usually can be controlled using radioactive iodine (131I); chemotherapy is not effective. Most often, the surgeon does a total thyroidectomy, per- forming a lymph node dissection only when metastases are identiﬁed; modiﬁed radical neck dissection preserves the sternocleidomastoid muscle, spinal accessory nerve, and jugular vein while cleaning out the lymph nodes lateral to the thyroid and along the trachea. For follicular cancers, the surgical approach is similar; however, these lesions are more likely to spread via the bloodstream and are not as easily controlled with 131I when metastatic. Anaplastic carcinomas are rare thyroid neoplasms that are highly aggressive, extensive (almost impossible to remove), and resistant to therapy. The surgical approach is to try to clear the anterior wall of the trachea and remove all cancer locally, if possible; tracheostomy may be necessary. More recently, the ret proto-oncogene has been used to determine the presence of this cancer prior to changes in the calcitonin levels, allowing even earlier surgical intervention. The surgical approach is aggressive, consisting of total thyroidectomy with meticulous “central compartment” dissection and ipsilateral modiﬁed radical neck dissection. In determining the management of papillary and follicular thyroid cancer, the relative risk of recurrence and death is evaluated so as to plan the most effective treatment. In patients with thyroid cancer, a man over 40, a woman over 50, and anyone with distant metastases or cancer involving both lobes or invading adjacent tissues is classiﬁed as “high risk. Involvement of one or two nearby lymph nodes may increase the risk slightly but does not have the same signiﬁcance 198 J. These patients should be fol- lowed with periodic neck examinations and determination of the serum thyroglobulin levels. A very low thyroglobulin level is evidence against papillary cancer (or “Hürthle cell cancer”) recurrence. These patients present with high serum calcium levels and usually a hard mass in the neck. Perils and Pitfalls In any surgery of or near the thyroid, there is a risk of temporary or permanent injury to the recurrent laryngeal nerve and to the exter- nal branch of the superior laryngeal nerve. Removing or destroying too much parathyroid tissue carries the risk of producing severe hypoparathyroidism, which is difﬁcult to manage and very unpleas- ant for the patient. An extremely important complication, because it is life threatening, is an unrecognized postoperative compression of the trachea from an expanding hematoma after thyroid surgery. When called to see a postop- erative thyroid patient who has difﬁculty breathing, the responding physician must not hesitate to open the incision and spread the closed muscles to relieve the pressure on the trachea by releasing the trapped blood. Summary An overview of this complex topic has stressed diagnostic techniques, lesions, and cancers most frequently encountered in the head and neck. Appropriate referral, careful evaluation, and biopsy of suspicious lesions has been encouraged. We have stressed the need for careful, logical progression from detailed history-taking to choice of appropriate diagnostic testing, only after careful physical examination. Oropharyngeal and neck lesions, in smokers, are especially worrisome because of the greatly increased risk of cancer in these individuals. Abnormalities of the thyroid cause most lumps of the neck that trigger a visit to a physician’s ofﬁce. Relative contribution of tech- netium-99m sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism. Thyroid carcinoma: biological implications of age, method of detection, and site and extent of recurrence. To discuss the anatomy and physiology of the swallowing structures and mechanism, including the physiologic lower esophageal sphincter. To discuss pertinent clinical history and physical examination ﬁndings as they relate to structural and functional pathology. To describe various therapeutic options for patients with neurologic, neoplastic, reﬂex- mediated, and dysmotility-mediated disorders. Cases Case 1 A 58-year-old man presents to your ofﬁce complaining of difﬁculty in swallowing. Case 2 A 39-year-old woman presents to your ofﬁce with burning chest pain, rapidly worsening over 3 years. Case 3 A 72-year-old woman presents to your ofﬁce with difﬁculty in swal- lowing for decades. Swallowing Difﬁculty and Pain 201 Introduction The swallowing mechanism is a complex interaction of pharyngeal and esophageal structures designed for the seemingly simple purpose of propelling food to the stomach and of allowing the expulsion of excess gas or potentially toxic food out of the stomach. Initial evaluation of a patient complaining of difﬁculty (dysphagia) or pain (odynophagia) with swallowing involves a thorough, focused history and a physical examination.
Medical Word Elements This section introduces combining forms buy clindamycin online pills, suffixes buy genuine clindamycin on line, and prefixes related to the special senses generic 150 mg clindamycin visa. Element Meaning Word Analysis Combining Forms Eye ambly/o dull, dim ambly/opia (˘am-bl ¯e-O-p ¯¯ e-˘a): dimness of vision -opia: vision In amblyopia, visual stimulation through the optic nerve of one eye (lazy eye) is impaired, thus resulting in poor or dim vision. Because of diminished blood flow to the back of the eye, the optic nerve appears pale gray, hence the name glaucoma. Young children are especially vulnerable to middle ear infections that, if not treated, may cause Common signs and symptoms of eye disorders hearing loss. For diagnosis, treatment, and manage- include decrease in visual acuity,headaches,and pain in ment of hearing disorders, the medical services of a the eye or adnexa. Otolaryngology is the are serious but asymptomatic; therefore, regular eye medical specialty concerned with disorders of the checkups are necessary. The physician who treats these management of visual disorders, the medical services disorders is called an otolaryngologist. Audiologists are the medical specialty concerned with disorders of the allied health-care professionals who work with eye. The physician who treats these disorders is called patients with hearing, balance, and related problems. Optometrists work with ophthal- They perform hearing examinations, evaluate hear- mologists in a medical practice or practice independ- ing loss, clean and irrigate the ear canal, fit and dis- ently. They diagnose vision provide audiological rehabilitation, including audi- problems and eye disease,prescribe eyeglasses and con- tory training and instruction in speech or lip reading. Although they cannot perform surgery, they common- Eye Disorders ly provide preoperative and postoperative care. A complete examination myopia, the eyeball is too short and the image falls of the eye and its adnexa is necessary to identify behind the retina. Distant objects are seen and lacrimal structures are examined and intraoc- clearly, but near objects are not in proper focus. If infection is another form of ametropia called astigmatism detected, it must be located and identified by cul- (Ast), the cornea or lens has a defective curvature. An alternative to cor- important because many eye disorders have a genet- rective lenses is laser-assisted in situ ker- ic predisposition, including glaucoma. This procedure disorders include errors of refraction, cataracts, changes the shape of the cornea and, in most glaucoma, strabismus, and macular degeneration. The flap Errors of Refraction is lifted to the side while a laser reshapes the An error of refraction (ametropia) exists when underlying corneal tissue. The proce- may be due to a defect in the lens, cornea, or the dure usually takes less than 15 minutes. Some image falls in front of the retina, causing near- medical conditions, certain medications, or the sightedness. Glaucoma may occur as a primary or con- Cataracts are opacities that form on the lens and genital disease or secondary to other causes, such impair vision. These opacities are commonly pro- as injury, infection, surgery, or prolonged topical duced by protein that slowly builds up over time until corticosteroid use. Chronic glaucoma may produce result of genetic defects or maternal rubella during no symptoms except gradual loss of peripheral the first trimester of pregnancy. Headaches, blurred cataract is treated in the same manner as age-related vision, and dull pain in the eye may also be pres- cataract. Cupping of the optic discs may be noted on ed lens by emulsifying it using ultrasound or a laser ophthalmoscopic examination. If particles that can be removed through the tiny inci- untreated, acute glaucoma causes complete and sion. The surgery ing test that measures intraocular pressure by is usually performed using a topical anesthetic, and determining the resistance of the eyeball to inden- the incision normally does not require stitches. Treatment for glaucoma all of them eventually lead to blindness unless the includes medications that cause the pupils to con- condition is detected and treated in its early strict (miotics), which permits aqueous humor to Artificial lens Lens capsule Cataract removal Artificial lens insertion Figure 15-5. Eye showing normal flow of aqueous humor (yellow arrows) and abnormal flow of aqueous humor (red arrow) causing destruction of optic nerve. The devi- Strabismus ation may be a constant condition or may arise Strabismus, also called heterotropia or tropia, is a intermittently with stress, exhaustion, or illness. Applanation tonometry using a slit lamp to measure intraoc- ular pressure (courtesy of Richard H. Blood and other fluids leak but not always, associated with “lazy-eye syn- from these vessels and destroy the visual cells, leading drome” (amblyopia). Vision is suppressed in the to severe loss of central vision and permanent visual “lazy” eye so that the child uses only the “good” eye impairment. The vision pathway fails to develop in gery can be employed to destroy the newly forming the “lazy” eye. There is a critical period during which ambly- It is successful in about one half of the patients with opia must be corrected, usually before age 6. However, the effects of the procedure detected and treated early in life, amblyopia can commonly do not last and new vessels begin to form. It commonly drusen develop on the macula and interfere with consists of covering the normal eye, forcing the central vision.
These people indeed may have made signiﬁcant contributions to your problems cheap clindamycin 150 mg, and that’s useful to know purchase 150 mg clindamycin otc. Part I: Analyzing Angst and Preparing a Plan 24 Worksheet 2-2 My Emotional Origins Questions About Mother (or other caregiver) 1 buy clindamycin discount. Were there special circumstances (for example, illness, death, divorce, military service, etc. Does anything else important about her come to mind, whether positive or negative? Were there special circumstances (for example, illness, death, divorce, military service, etc. Does anything else important about him come to mind, whether positive or negative? From daily trafﬁc hassles to major losses, stressful events deplete your coping resources and even harm your health. Complete The Current Culprits Survey in Worksheet 2-3 to uncover the sources of your stress. You can’t make your world less stressful unless you ﬁrst identify the stress-causing culprits. In the past year or so, have I lost anyone I care about through death, divorce, or prolonged separation? Are there problems at work such as new responsibilities, longer hours, or poor management? Have I made any major changes in my life such as retirement, a new job, or a new relationship? Do I have daily hassles such as a long commute, disturbing noises, or poor living conditions? However, all major changes, whether positive or negative, carry signiﬁcant stress that tags along for the ride. Part I: Analyzing Angst and Preparing a Plan 30 Drawing Conclusions You didn’t ask for depression or anxiety. Your distress is understandable if you examine the three major contributors: biology/genetics, your personal history, and the stressors in your world. Take a moment to summarize in Worksheet 2-4 what you believe are the most impor- tant origins and contributors to your depression or anxiety. Physical contributors (genetics, drugs, illness): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 2. My personal history: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 3. The stressors in my world: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ As you review your summary, we sincerely hope you conclude that you’re truly not at fault for having depression or anxiety. At the same time, you’re responsible for doing something about your distress — no one can do the work for you. Just remember that working on your emotional distress rewards you with lifelong beneﬁts. Chapter 3 Overcoming Obstacles to Change In This Chapter Uncovering change-blocking beliefs Busting beliefs Sleuthing self-sabotage Slicing through self-sabotage ou don’t want to feel depressed or anxious. You want to do something about your distress, but you may feel overwhelmed and incapable. But ﬁrst, you have to understand and overcome the obstacles in your mind that prevent you from taking action and moving forward. In this chapter, we help you uncover assumptions or beliefs you may have that make it hard for you to tackle your problems. After you identify the beliefs that stand in your way, you can use a tool we provide to remove these obstacles from your path. We also help you dis- cover whether you’re unconsciously sabotaging your own progress. If you discover that you’re getting in your own way, we show you how to rewrite your self-defeating script. Discovering and Challenging Change-Blocking Beliefs You may not be aware that people hold many beliefs about change. Others think they don’t deserve to be happy and there- fore don’t change their lives to improve their situations. By stealing your motivation to change, assumptions such as these can keep you stuck in a depressed or anxious state. And, unfortunately, most people aren’t aware of when and how these underlying assump- tions can derail the most serious and sincere efforts for making changes. The quizzes in this section are designed to help you discover whether any change-blocking beliefs create obstacles on your road to change.