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In patients 60 years of age rhinocort 100 mcg low price allergy shots in abdomen, consider screening ligaments proven 100mcg rhinocort allergy forecast nc, tendons order rhinocort 100mcg with mastercard allergy medicine safe pregnancy, bursae 100mcg rhinocort fast delivery allergy medicine plus alcohol, or soft tissues. Pain may also for associated disorders such as hemochromatosis, hy- be referred from a neuropathic condition or pathology perparathyroidism, and hypothyroidism. Monarthritis of acute onset (hours to calcium hydroxyapatite crystals is more dif?cult be- days) usually indicates trauma, infection, or a crystal- cause it requires electron microscopy or Alizarin Red induced process. If analysis of synovial ?uid does not reveal the diagno- condition such as atypical infection, osteoarthritis, sis, radiographs of the affected joints and contralat- tumor, or systemic in?ammatory disease. Aspiration of the affected joint for synovial ?uid analy- include osteoarthritis and chondrocalcinosis (suggest- sis is always indicated to evaluate monarthritis. Repeat synovial ?uid analy- tests do not generally improve diagnostic sensitivity. In endemic areas, a measurement to separate nonin?ammatory from in- Lyme titer should be sent, especially if there is a his- ?ammatory processes. With appropriate clinical corre- tory of rash, tick bite, or appropriate exposure. Polymorphonuclear detecting a systemic in?ammatory disease such as an leukocyte-predominant effusions ( 75% cell count) atypical presentation of rheumatoid arthritis or sys- also indicate an acute in?ammatory process. If the diagnosis is still not clear, close observation is rapid treatment is warranted to prevent irreversible warranted. Alternatively, additional axial or peripheral may be divided into nongonococcal and gonococcal arthritic symptoms may develop to suggest evolution causes. Gram-positive organisms, particularly Staphylo- into a systemic in?ammatory disease. If monarthritis coccus aureus, are the most common agents to cause persists for 4–6 weeks in the absence of a clear diagno- nongonococcal bacterial arthritis. Nongonococcal in- sis, synovial biopsy should be considered to diagnose fection is often associated with a primary focus of infec- tuberculous or fungal infections, amyloid, pigmented tion elsewhere. Nonin?ammatory, nonbloody effusions should prompt tion should be presumed to represent septic arthritis. Neuropathic arthropathy is most ing macules, pustules, and vesicles, may also be pres- commonly associated with diabetes but may occur in a ent. In such cases, synovial biopsy is there is a history of trauma with persistent clicking, lock- warranted for further diagnosis. A thorough history and physical examination are re- inside the ears, gluteal cleft, lateral margins of the quired for the evaluation of polyarthritis. Historical feet), nail pitting, dactylitis (sausage digit), diarrhea features of interest include duration of symptoms; prior or abdominal pain, urethritis, pyoderma gangreno- episodes of arthritis; and distribution, presence, and sum, uveitis, or keratoderma blennorrhagica. A complete review of graph of the pelvis may show sacroiliitis but only after systems is also required to assess for systemic illnesses years of disease activity. Symmetry of joint involvement is a useful distinguish- Raynaud’s phenomenon, lupus symptoms (in particular, ing characteristic of the polyarthritides, but it is not alopecia, photosensitivity, pleurisy, oral ulcers), visual absolute. Patients should also be questioned about metrically, especially early in its course. Similarly, an functional limitations (opening jars, holding or lifting “asymmetric arthritis” can rarely present with com- objects, climbing stairs, dressing self). The arthritis of lupus can pain or stiffness with prolonged immobility (gelling), be subtle, and the examination is often normal. There may be an effu- aud’s phenomenon can be the presenting symptoms of sion, crepitus, and pain to palpation along the joint scleroderma. Cell counts of 2000 cells/mm3 are consistent asymmetric polyarthritis with or without axial involve- with an in?ammatory effusion. In?ammatory arthritis with a clear axial component is crobes can cause polyarthritis, especially streptococ- highly suggestive of a spondyloarthropathy: ankylos- cal infections. Relapsing poly- phalangeal joints, wrists, elbows, shoulders, ankles), or chondritis can affect cartilage in joints, ears, nose, tra- unusual radiographs should prompt an evaluation for cheobronchial tree, and proteoglycan-rich structures secondary causes. Mediterranean fever, hyperimmunoglobulin D syn- drome, tumor necrosis factor receptor–associated peri- odic syndrome, Muckle-Wells syndrome). Polyarthritis: the differential diagnosis of rheumatoid leukemic arthritis, and the arthritis associated with arthritis. Diagnosis and management of rheumatoid ing bony hypertrophy and cartilage space loss is consis- arthritis. The algorithm for this chapter starts at a point where a ?oor (and may bend the legs slightly so as to avoid a patient is suspected of in?ammatory arthritis and sero- false-positive test result because of hamstring tight- logic testing is negative for rheumatoid factor. Chest expansion 30 minutes, improvement rather than worsening with should be measured from forced expiration to full in- exercise, and soft-tissue swelling. An infectious workup is indicated in multiple joints and the intervening soft tissue are the event of acute onset of seronegative arthritis with in?amed in a single digit, creating a “sausage digit” (dac- or without extracellular manifestations. Clinically and by low back pain and stiffness, neck pain and stiffness, histologically similar lesions can occur acutely in reac- or posterior thoracic pain with deep breathing or tive arthritis: keratoderma blennorrhagica of the feet, coughing. Schober’s test is sensitive for lumbar spine circinate balanitis, and nail pitting. Conjunctivitis is part of the classic triad of Reiter’s featuring disk shrinkage and marginal osteophytes syndrome. A recent history of self-limited diarrhea that features exuberant ossi?cation at sites of tendon and abdominal pain suggests a precipitating episode of and ligament attachment, including the spine, often in gastroenteritis; a chronic history raises suspicion for a patchy distribution and usually on the right side. Patients with reactive arthritis may develop cardiac conduction defects that are generally not serious. Am Fam Physician the ascending aorta, leading to aortic valve insuf?- 2004;69:2853–2860. Practitioners differ greatly on how that includes both focal pain associated with easily de- much laboratory evaluation to do related to these ?ned nonarticular musculoskeletal structures (tendon- considerations. Pain with ately positive results are very common in the healthy passive movement, if it occurs, should be with increas- population. Fibromyalgia is a common idiopathic disorder with no tive of tendonitis or muscle strain is pain produced by known pathology, characterized by widespread pain isometric use of an involved muscle and tendon be- and tenderness on examination in a number of charac- cause the joint does not move. Irritated or damaged teristic areas, including the trapezii, the attachment of tendons are usually not visibly in?amed (no redness or neck extensors to the occiput (and other areas of the swelling) unless in the setting of signi?cant trauma or neck and upper back), the joining of the second rib to an in?ammatory disease (especially the seronegative the sternal cartilage, the upper outer buttock, the lat- spondyloarthropathies), but there is often point tender- eral elbow, the lateral hip near the greater trochanter, ness. Many patients are tender at other swelling and redness, at particular locations, including or all soft-tissue locations as well. There is often associ- the front of the patella (prepatellar), the point of the ated sleep disorder, depression, lack of exercise, chronic elbow (olecranon), the lateral aspect of the shoulder fatigue, headache, irritable bowel syndrome, and some- (subdeltoid or subacromial), the medial aspect of the times another, locally painful condition of de?nable proximal tibia (anserine), the greater trochanter of the cause. These factors may play a role in amplifying pain femur (trochanteric), and the ischial tuberosity (ischial). Intraarticular pain is usually experienced on both pas- of tendons near the bursa and is worsened by stretch sive and active motion.

Pathology: diffuse spongiform encephalopathy with widespread neuronal loss generic rhinocort 100 mcg overnight delivery allergy treatment sacramento, gliosis buy discount rhinocort 100mcg on-line allergy forecast huntsville tx, and amyloid plaques d 100mcg rhinocort otc allergy testing false negative. Hyperintensity in anterior putamen and caudate head is known as the hockey-stick sign cheap rhinocort 100mcg without a prescription allergy symptoms pet dander. Subacute progressive ataxia/parkinsonian disorder with later-onset cognitive impairment d. Pathology: spongiform changes are seen; Kuru-like plaques in cerebellum and other areas. Loss of circadian rhythm with insomnia to <2 hours; behavioral changes, in- cluding inattention, poor concentration and memory, hallucinations; dementia is rare. Pathology: spongiform degeneration with severe neuronal loss and reactive gli- osis in anterior and dorsomedial thalamic nuclei d. Tribes in New Guinea (particularly in women and children) secondary to con- sumption of brain and/or mucosal and cutaneous contact with neural tissues b. Diagnosis/pathology: neuronal loss highest in cerebellum, basal ganglia, thalamus, Sc and mesial temporal lobes; PrP reactive plaques called Kuru plaques at highest density in the cerebellum. Caused by Naegleria fowleri that inhabits soil and water (especially warm climates) 2. Pathology: purulent meningitis with microabscesses and extensive necrotizing destruction of parenchyma 5. Severe headache, fever, nausea, vomiting, meningeal signs, seizures, hallucina- tions, altered consciousness progressing to coma b. Humans are infected by eating undercooked meat or by ingestion of contaminated cat feces. Transmission of the infection from mother to fetus when women acquire the infection during pregnancy b. Clinical: hydrocephalus, microcephalus, intracranial calcifications, mental retardation, seizures, deafness, blindness, and hepatomegaly c. Cerebral toxoplasmosis: pyrimethamine (100–200 mg the first day, followed by 50–75 mg/day) plus sulfadiazine (4–6 g/day) for >2 months b. Supplement with folate, 8 to 10 mg/day, to avoid the toxic effects of pyrimethamine. Chronic stage: dilated cardiomyopathy, cardioembolic stroke due to heart disease, megacolon, and megaesophagus e. Diagnosis: microscopic examination of thin and thick blood smear demon- strate the parasite in the acute phase. Painful erythematous nodules associated with regional lymphadenopathy that disappear spontaneously ii. Stage I (lasting months): Winterbottom’s sign—fever, cervical lymphade- nopathy, and hepatosplenomegaly iii. Acquired by ingesting its eggs from contaminated water/food or by the fecal–oral route 3. Cystic lesions with or without contrast enhancement and surrounding edema; cysts can be meningobasal, parenchymal, or intraventricular. Intestinal nematode infection due to ingestion of undercooked pork containing encysted larvae of Trichinella spiralis. Rarely, in acute phase may have cerebral symptoms due to emboli from trichinella myocarditis 4. Pathophysiology: a primary source is pesticides; reacts with sulfhydryl groups of proteins and interferes with several steps of metabolism in the neuron, producing dying-back-type axonal degeneration, particularly in myelinated fibers 2. Acute gastrointestinal symptoms followed by painful paresthesia with progres- sive distal weakness c. Hyperkeratosis and sloughing of the skin on the palms and soles may occur several weeks after acute poisoning, followed by a chronic state of redness and swelling of the distal extremities. Acute: salivation and severe gastrointestinal dysfunction followed by hallucina- tions and delirium b. Constriction of visual fields, ataxia, dysarthria, decreased hearing, tremor, and dementia iii. Minamata disease: methylmercury (MeHg) poisoning from ingestion of fish and shellfish contaminated by MeHg discharged in waste water; typical symp- toms include sensory disturbances (glove and stocking type), ataxia, dysarthria, constriction of the visual field, auditory disturbances, and tremor 2. Moderate doses produce neuropathic symptoms in less than 48 hours consisting of pain and paresthesia, followed by ascending sensory loss and distal weakness. More likely to present with neuropathy, predominantly, but not exclu- sively, the radial nerve d. Typical clinical triad (A) Abdominal pain and constipation (B) Anemia (C) Neuropathy b. Adult (A) Prodrome: progressive weakness and loss of weight (B) Ashen color of the face (C) Mild persistent headache (D) Fine tremor of the muscles of the eyes, tongue, and face (E) Progression into encephalopathic state (F) May have focal motor weakness ii. Lead lines on gums (also known as Burtonian line)—stippled blue line seen in 50% to 70% of patients with chronic lead poisoning b. Severe encephalopathy: mortality high but lessened by the use of combined chelating agent therapy c. Residual neurologic sequelae: blindness or partial visual disturbances, per- sistent convulsions, personality changes, and mental retardation d. Personality changes consisting of irritability, lack of sociability, uncontrollable laughter, tearfulness, and euphoria 3. Supportive care: induction of vomiting, gastric lavage, maintenance of ad- equate ventilation, correction of acidosis, and control of vital signs ii. Tin: Triethyltin exposure acutely results in white-matter vacuolation; with chronic exposure, demyelination and gliosis are seen. Methanol itself is only mildly toxic, but its oxidation products (formaldehyde and formic acid) induce a severe acidosis. Methanol may cause bilateral hemorrhagic necrosis of the caudate, putamen, pons, optic nerves, cerebellum, and subcortical white matter. Treatment: three-part approach—ethanol, bicarbonate, dialysis (in severe cases) B. Pathophysiology: used as antifreeze, tobacco moistener, and in paint; toxic dose is greater than 100 mL 2. Restless and agitation followed by somnolence, stupor, coma, and even convulsions b. Characteristic metabolic findings: metabolic acidosis with large anion gap, hypocalcemia, and calcium oxalate crystals in the urine 3. Neurologic: lethargy that progresses to coma followed by brainstem dysfunc- tion and movement disorders 4. May be absorbed through the skin, mucous membranes, gastrointestinal tract, and lungs B. Increased spontaneous firing rate and amplitude of the miniature end-plate potentials b. Reversal of peripheral acetylcholinesterase for proportion of enzyme that has not irreversibly bound the inhibitor V. Pathophysiology: inhibition of ferric-ion-containing enzymes, including cytochrome oxidase (produces tissue hypoxia by inhibiting the action of respiratory enzymes) 2.

Incisions into the kidney are usually made along the convex lateral border (Brodal’s line) as this does not involve cutting of large vessels within the kidney buy 100mcg rhinocort fast delivery allergy testing vancouver bc. Sometimes a stone may destroy much of the renal substance 100 mcg rhinocort with mastercard allergy fatigue, and if the other kidney is healthy rhinocort 100mcg free shipping allergy shot serum, the entire kidney may have to be removed (nephrectomy) rhinocort 100 mcg on-line allergy medicine 4 month old. In percutaneous removal of stones, an instrument called a nephroscope is passed into the renal pelvis along a needle introduced through the loin. Stones can be seen and can be removed whole or after break- ing them into small pieces. In lithotripsy, an instrument (lithotriptor) generates powerful shock waves that can pass through tissues of the body and can be focused at a given site. Such waves can reduce a stone to sand, or to very small pieces, which can then be fushed out through the urinary passages. Unfortunately, these newer tech- niques are expensive and not suited to all patients. This is more likely to occur at places where the ureter is normally constricted (see chapter 33). In one of these, a ureteroscope is passed into the ureter (through the urethra and urinary bladder). Urinary obstruction caused by calculi or other causes can lead to dilatation of the ureter above the site of ob- struction (hydroureter). Infections of the lower urinary tract are common and they can ascend to the renal pelvis and kidney sub- stance. Sometimes the kidney can be reduced to a bag of pus, most of the kidney tissue being destroyed (pyonephro- sis). Infection from a kidney can spread to tissues around it leading to a perinephric abscess. A perinephric abscess can also be caused by infection reaching the region through the circulation, or from other organs in the region (e. As implied by the name the right and left suprarenal glands lie in close relationship to the upper poles of the corresponding kidneys. They are enclosed with the kidney in the renal fascia, but lie outside the renal capsule (30. Each suprarenal gland is relatively fat and has an anterior and a posterior surface. Each gland is about 50 mm in vertical diameter, about 30 mm from side to side, and about 10 mm from front to back. The posterior surface of each suprarenal gland rests (in its upper part) on the diaphragm, and (in its lower part) on the superomedial part of the corresponding kidney. Medial to each gland there is the corresponding crus of the diaphragm on which there is the correspond- ing coeliac ganglion, and the corresponding inferior phrenic artery (a branch of the abdominal aorta). The anterior surface of the right suprarenal gland can be divided into medial and lateral parts by a vertical line. The upper half of the lateral part is in contact with the bare area of the liver, while its lower part is separated from the visceral surface by peritoneum. The upper part of the anterior surface is covered by the peritoneum forming the posterior wall of the lesser sac. The lower part of the anterior surface is overlapped by the splenic artery and the body of the pancreas. In addition to the crus of the diaphragm and the coeliac ganglion (common to both sides) the left gastric artery lies medial to the left suprarenal gland. The gland is made up of a superfcial layer the cortex, and a deeper part called the medulla. Both the medulla and the cortex consist of cords or groups of cells separated by sinusoids. On the basis of the arrangement of its cells the cortex can be divided as follows: a. Here, the cells are arranged in the form of inverted U-shaped structures, or acinus-like groups. This layer is made up of cords of cells that branch and anastomose with each other forming a kind of reticulum. The medulla is made up of groups of cells, some of which may be arranged in columns. The hormones produced by the suprarenal glands are as follows: Horm ones of the suprarenal cortex a. The cells of the zona glomerulosa produce the hormone aldosterone that helps to maintain the water and elec- trolyte balance of tissues. These have widespread ef- fects all over the body, including the maintenance of carbohydrate balance. The cells of the zona reticularis probably produce sex hormones including progesterone, oestrogens and andro- gens. Both functionally and embryologically the medulla of the suprarenal gland is distinct from the cortex. This is called the chromaffin reaction and the cells that give a positive reaction are called chromaffin cells. The cells of the suprarenal medulla are modifed postganglionic sympathetic neurons. Like typical postganglionic sympathetic neurons they secrete noradrenalin and adrenalin into the blood mainly at times of stress (fear, anger etc. On the right side it drains into the inferior vena cava, and on the left side into the left renal vein. The medulla of the suprarenal gland receives numerous preganglionic sympathetic nerves. Adrenal cortical tissue may be present at various ectopic sites including the kidney substance, the ovaries and the broad ligament. Congenital hyperplasia (over-development) of the cortex in the males leads to the adrenogenital syndrome marked by very early development of secondary sexual characters. In the female it may cause enlargement of the clitoris and the child may be mistaken for a male (pseudo- hermaphroditism). After puberty hyperplasia of the adrenal cortex, or a cortical tumour, leads to Cushing’s syndrome. In this syndrome, seen mostly in females, there is abnormal deposit of fat in the face, neck and trunk but the limbs remain thin and weak. Cortical hyperplasia in infancy has been mentioned under congenital malformations. Tumours in the adrenal may arise from sympathetic nervous tissue (neuroblastoma) or from chromaffn cells (phaeochromocytoma).

Everybody should be intercultural interactions are characterized by culturally competent order rhinocort 100 mcg mastercard allergy testing omaha ne. Faculty who are cultur- issues order 100 mcg rhinocort with visa allergy steroid shot, therefore generic rhinocort 100mcg online allergy testing in child, needs to be embedded through- ally aware are most likely to incorporate cultural out the curriculum and should permeate all aspects content in their teaching activities and to model of the educational process purchase rhinocort 100 mcg mastercard allergy report nyc. It is important will be adequate to ensure learner growth in terms that all educators, not just those who specialize in of increased cultural awareness’ (Carpio & Majum- cultural issues, incorporate cultural awareness dar 1992, p. Garan (2005) provided a tion that are crucial in improving competency checklist for cultural competence that is an excel- (Carpio & Majumdar 1992, Robison 1996). A means of checking tive clinical reasoning (Carnevali 1995, Refshauge current knowledge and understanding is essential, & Higgs 1995). One way of enhancing self-monitor- because clinical intervention should be based upon ing skills is for novice reasoners to systematically an informed judgement concerning the client’s apply a series of questions or an organizational condition or potential dysfunction (Bridge & framework to thinking activities (see Bridge & Twible 1997). Cultural awareness, may be missed because the therapist does not pick knowledge acquisition, and use of knowledge up a cultural prompt (an indication that consider- about cultures are critical elements of effective ation of culture is particularly important) or the clinical reasoning and should be part of the organi- therapist does not have culture-specific knowledge zational framework. Parallels exist in these pro- the clinical reasoning process are ‘issue/problem cesses in the tasks of problem sensing and cultural sensing’ and ‘issue/problem validation or inter- awareness, knowledge acquisition, and the use of vening’ (Neistadt 1992, Rogers & Holm 1991). Fitzgerald et al 1996, Garan As novice reasoners, students should be taught to 2005, Robison 1996) describe ‘cultural awareness consider culture routinely throughout their interac- competency’ and ‘knowledge competency’ (cf tions with clients (that is, during assessment, inter- Table 44. One educational strategy acquisition or cultural knowledge acquisition is to link culture to the existing clinical reasoning poses few problems for students. Students’ diffi- teaching, so that it pervades all aspects of the cur- culties lie firstly in recognizing the need to riculum and is incorporated into all case study ana- acquire the knowledge and secondly in applying lyses undertaken. Factors that need to be considered that knowledge effectively in clinical decision include the social and cultural background of the making as part of the therapy process. Therefore client, the beliefs and values in the client’s culture it is imperative in curricula to address both cul- (and how they differ from the therapist’s beliefs tural awareness and the application of cultural and values), as well as the limitations of the thera- knowledge, in order to promote effective cultural pist and the environment in which the service is reasoning. Development of this knowledge and awareness needs to be fostered in Issue/problem sensing or Cultural awareness students. The sources we draw upon to inform validation, treatment us about our state of health and to explain it to choices) as the basis for others have been classed as popular, professional clinical intervention and traditional (Kleinman 1980). On the basis of these sources of ideas and information, different Teaching clinical reasoning and culture 465 explanatory models are formed to describe or Cultural knowledge acquisition explain illness and disability. It is often difficult to match to acquire the necessary knowledge from available the therapist’s perception of a particular illness or literature. For cultural information, there are two disability with the client’s understanding or expe- other important sources: (a) cultural informants or rience of it. The disparity is likely to be even greater brokers, and (b) clients and family members and when the client and the health professional come other community members of the cultural group. Thus, any Fitzgerald et al (1995), Garan (2005) and Parasyn clinical interaction can involve perspectives from (2005) have provided valuable guidance to assist in multiple cultures and several systems within each the development of cultural knowledge. One of the skills that therapists regularly outlined key principles to consider in acquiring use to gain information regarding clients’ beliefs cultural knowledge, frameworks for exploring cul- and cultural influences is the history-taking tural issues relevant to individual practitioners process. The therapist assimilates vely listens to the client’s story and establishes all available sources of knowledge, and validates a relationship with the client. Invari- incorporate information from the affective and ably, the more valid or relevant the level of knowl- knowledge domains of the client’s story into future edge invoked, the greater the confidence the clinical decisions, they set the scene for a culturally therapist will have in that knowledge and the appropriate client-centred approach to service smaller the degree of uncertainty ure 44. Cultural influences should routinely be consid- Using cultural knowledge appropriately, or ered within clinical narratives, since cultural validation of issues and problems awareness enables therapists to identify what knowledge needs to be acquired. To facilitate stu- Cultural knowledge can be used to determine dent learning of the cultural clinical reasoning appropriate modes of communication and forms process, case stories with a cultural component of assessment of clients when conducting obser- should be incorporated into undergraduate tuto- vation of their performance of functional activ- rial sessions; role-plays and use of critical incident ities and physical examination. In addition, methodology (Fitzgerald et al 1995) are strategies cultural knowledge informs students as they that have been used successfully. Simulation develop working hypotheses, validate assessment experiences, such as BaFa BaFa (Shirts 1977) and findings and select and implement a management NaZa NaZa (Newfields 2001) also have been used programme having considered the implications, successfully to improve cultural awareness in stu- assessed the risks and determined the expected dents; Newfields (2001) considered that the focus outcomes. The focus in validation of issues and of ‘learning-by-doing’ engages learners more problems is on the examination of discrepancies fully and moves them to a deeper level of cross- between the original clinical image and the real cultural understanding. Perhaps the greatest and gradually unfolding clinical scenario (Bridge benefit in such simulations is that participants & Twible 1997), and this validation process incor- gain a deeper perspective of their own values porates the application of cultural knowledge. Such simula- Parasyn (2005) also strongly advocated the use tion exercises do not help students to cope with of cultural brokers as critical in the successful all types of intercultural conflict, but do focus application of community development activities. Such workshops often use critical incident all participants methodology (Brislin et al 1986, Brislin & Yoshida Select interventions that consider cultural 1994) and explanatory models (Kleinman 1980)as restrictions or taboos, common practices and reflective frameworks to identify cultural issues available resources and to understand clients’ perceptions of health, Engage in continual assessment of the level illness and service delivery. Others use checklists and appropriateness of cultural knowledge for cultural competence as a starting point to creat- Substitute joys and challenges for problems ing a favourable cultural environment, to ensure and frustrations that all members of the organization, be they cleaners, administrative staff or health providers, are culturally aware and culturally competent (Garan 2005). This programme involves realms of community development (Twible & student fieldwork placements in community- Henley 1998). Some have completed higher degrees in interna- During the programme a variety of activities fur- tional health, seeking international development ther fostered students’ cultural awareness and work through government and non-government their capacity to engage in ‘cultural reasoning’. Parasyn 2005); some involved in travelling to remote areas of a country have worked as youth ambassadors in developing quite different from their own to living in unfamil- countries (Tonga, Samoa, Solomon Islands, Sri iar environments and interacting with people Lanka); still others have used their cultural com- whose lives were culturally dissimilar to their petency skills in working with linguistically and own. In addition, the students learned a great deal culturally diverse groups in Australia (Garan about performing the tasks of clinical reasoning 2005). Many have chosen community practice as and clinical practice in the context of the local their preferred option for employment because people’s culture. In most situa- When the students were interviewed after their tions, these therapists are used by their peers to placements, it was apparent that the fieldwork take on the most culturally challenging and com- experience highlighted for them the impact of plex clients and are recognized as a ‘cultural interaction with the host country’s culture on their resource’. That is, people can be demonstrate the importance of understanding the exposed to cultural differences, but exposure alone unique nature of culture, both as a concept and as does not necessarily improve one’s cultural com- part of the reality of all of the participants involved petency (Robison 1996). A cultural interaction that in the processes of clinical reasoning and clinical allows the therapists to experience different cul- practice. It is important to recognize that each indi- tures positively arises from the development of vidual presents differently and that assumptions skills in cultural awareness and acknowledgement cannot be applied to all people associated with a of alternative beliefs. Clinical competencies, commu- Students reflected that in order to provide nication skills, cultural strategies, a culturally effective therapy, they had to seek knowledge aware attitude and compassion are significant fac- specific to the host culture (from local cultural tors that have been identified as common across all brokers) and consider the cultural factors that intercultural clinical interactions, whether at home would have an impact on therapy. The students reported that personal values tent therapists, the context is not an obstacle. Physical and (eds) Occupational therapy: enabling function and well Occupational Therapy in Pediatrics 11(4):1–16 being, 2nd edn. Australian Occupational Therapy Journal interactions: modules for cross-cultural training 32:118–121 programs. Physical Brislin R W, Cushner K, Cherri C et al 1986 and Occupational Therapy in Pediatrics: Quarterly Intercultural interactions: a practical guide. In: Journal of Occupational Therapy 46(9):814–819 Higgs J, Jones M (eds) Clinical reasoning for the Newfields T 2001 NaZa NaZa: A classroom adaptation of a health professions. Journal of Nanzan p 179–190 Junior College 29(Dec):107–129 Carpio B A, Majumdar B 1992 Experiential learning: an Parasyn C 2005Aharenmen! In: Higgs H, Jones M (eds) the Rehabilitation Journal 7(2):5–6 Clinical reasoning for the health professions. Butterworth-Heinemann, Oxford, p 105–116 Journal of Rehabilitation Apr/May/June:1–5 Riggar T F, Eckert J M, Crimando W 1993 Cultural diversity Fitzgerald M H, Mullavey-O’Byrne C, Twible R L et al 1995 in rehabilitation: management strategies for Exploring cultural diversity: a workshop manual for implementing organizational pluralism. School of Occupational Therapy, Rehabilitation Administration 17(2):53–61 University of Sydney Robison S 1996 Exposure and education: the impact on the Fitzgerald M H, Mullavey-O’Byrne C, Clemson L et al 1996 cultural competency of physiotherapists.

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