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Oral Dreyfus H L 1992 What computers still can’t do: a critique of Surgery Oral Medicine Oral Pathology Oral Radiology artificial reason order mefenamic 500 mg with amex muscle relaxant causing jaundice. Kawahata N cheap mefenamic 500 mg with mastercard spasms due to redundant colon, MacEntee M I 2002 A measure of agreement In: Higgs J purchase mefenamic 500 mg without a prescription spasms constipation, Jones M (eds) Clinical reasoning in the health between clinicians and a computer-based decision professions buy mefenamic 250 mg free shipping spasms parvon plus, 2nd edn. Journal of p 95–106 Dental Education 66:1031–1037 Elstein A S, Shulman L S, Sprafka S A 1978 Medical problem Kay E J, Nuttall N M, Knill-Jones R 1992 Restorative solving: an analysis of clinical reasoning. Community Dentistry and Oral Engel G L 1977 the need for a new medical model: Epidemiology 20:265–268 a challenge for biomedicine. Science 196:129–136 Kleinman A 1988 the illness narratives: suffering, healing Ettinger R L, Beck J D, Martin W E 1990 Clinical decision- and the human condition. Special Knutsson K, Lysell L, Rohlin M 2001 Dentists’ decisions on Care in Dentistry 10:78–83 prophylactic removal of mandibular third molars: a Eva K W 2005 What every teacher needs to know about 10-year follow-up study. Medical Education 39(1):98–106 Epidemiology 29:308–314 Evans R G, Barer M L, Marmor T R 1994 Why are some Lafkin A W 1948 A history of dentistry. Aldine de Gruyter, New York Loftus S 2006 Language in clinical reasoning: learning and Field M J (ed) 1995 Dental education at the crossroads: using the language of collective clinical decision making. Institute of Medicine, National Unpublished PhD thesis, University of Sydney, Australia. Journal of Dental Epidemiology 15:314–316 Education 55:358–364 MacEntee M I, Hole R, Stolar E 1997 the significance of Foucault M (trans A M Sheridan Smith) 1973 the birth of the the mouth in old age. Vintage 45:1449–1458 Books, New York MacEntee M I, Thorne S, Kazanjian A 1999 Conflicting Fyffe H E, Nuttall N M 1995 Decision processes in the priorities: oral health in long-term care. Dental Update 22:67–71 Matthews D C, Gafni A, Birch S 1999 Preference based Gale J, Marsden P 1982 Clinical problem solving: the measurements in dentistry: a review of the literature and beginning of the process. Community Dental Gies W J 1926 Dental education in the United States and Health 16:5–11 Canada: a report to the Carnegie Foundation for the Maupome G, Sheiham A 2000 Clinical decision-making in? advancement of teaching. Carnegie Foundation, New restorative dentistry: content-analysis of diagnostic York thinking processes and concurrent concepts used in an Gozum M E 1994 Emulating cognitive diagnostic skills educational environment. European Journal of Dental without clinical experience: a report of medical students Education 4(4):143–152 using quick medical reference and Iliad in the diagnosis Montgomery K 2006 How doctors think: clinical judgement of difficult clinical cases. Oxford University Press, Symposium on Computer Applications in Medical Care, Oxford p 991 Norman G 2005 Research in clinical reasoning: past history Guest C B, Regehr G, Tiberius R G 2001 the life long and current trends. British Dental Journal 163:161–166 Reit C, Kvist T 1998 Endodontic retreatment behaviour: the Svenaeus F 2000 the hermeneutics of medicine and the influence of disease concepts and personal values. Kluwer Academic, Dordrecht Sadegh-Zadeh K 2001 the fuzzy revolution: goodbye to the White B A, Maupome G 2003 Making clinical decisions for Aristotelian Weltanschauung. Special Care in Medicine 21:1–25 Dentistry 23:168–172 Schon D A 1983 the reflective practitioner: how? Zadeh L A 2001 From computing with numbers to professionals think in action. Basic Books, New York computing with words: from manipulation of Schon D A 1987 Educating the reflective practitioner. Humanism and social justice 266 Demands of consumer groups, expectation of docu- Science and evidence 267 mentation, the need for accountability of services Theory development and conflict 268 and government intervention in service delivery the content of clinical reasoning in have made an impact on every therapist. Within occupational therapy 269 this context occupational therapists have a mandate the therapy context 269 to develop and implement therapy programmes Clients and their life contexts 269 aimed at promoting maximum levels of indepen- Theory and science 270 dence in life skills and optimal quality of life. The Personal beliefs of the therapist 270 process of occupational therapy in this context Attitude, behavioural expectancy and clinical consists of problem solving under conditions of reasoning 271 uncertainty and change (Mattingly & Fleming Internal frame of reference 271 1994, Rogers & Masagatani 1982). Therapists collect, classify and analyse information about clients’ abil- the Process of clinical reasoning 271 ity and life situation and then use the data to define Scientific reasoning 271 client problems, goals and treatment focus. Ethical reasoning 273 the importance of reasoning in occupational Conditional reasoning 273 therapy has been clearly established (Mattingly Pragmatic reasoning 273 & Fleming 1994, Parham 1987, Rogers 1983, Conclusion 274 Unsworth, 2005). However, several questions remain unanswered in seeking to understand the nature of clinical reasoning. How do therapists combine science, pra- ctical knowledge and their personal commitments to make decisions about their actions? First, a historical perspec- ability to organize the temporal, physical and tive of clinical reasoning in occupational therapy is social elements of daily living (Breines 1990; outlined, and parallels with the development of the Keilhofner & Burke 1977, 1983). Second, elements of thera- occupation and occupational therapy treatment pist knowledge that have been found to influence was influenced by the theories and beliefs of the the process of reasoning and ultimately determine moral treatment movement of the 18th and 19th occupational therapy action are examined. Third, centuries (Harvey-Krefting 1985) which acknowl- alternative notions about the process of thinking edged people’s basic right to humane treatment that results in clinical decision making in occupa- (Pinel 1948). Influential in the crea- therapy profession, elements of what is termed tion of treatment principles was a thinking mode clinical reasoning have been referred to as: treat- described by pragmatic theorist, John Dewey ment planning (Day 1973, Pelland 1987); the evalu- (1910), who claimed that actions of professionals ative process (Hemphill 1982); clinical thinking depended on a unique mental analysis through (Line 1969); a subset of the occupational therapy which they sought to obtain an understanding of process (Christiansen & Baum 1997); and problem the significance and meaning in a person’s every- solving (Hopkins & Tiffany 1988). The criteria for judging this significance, reasoning process has been described as a largely meaning and worth were practical, largely arbi- tacit, highly imagistic and deeply phenomenologi- trary, qualitative rather than quantitative, non- cal mode of thinking, ‘aimed at determining “the specialized and purposive (Stanage 1987). Clinical good” for each particular client’ (Mattingly & reasoning of the time took the form of common- Fleming 1994, p. This expectancies held by the therapist (Chapparo early pragmatic view of the subjective and indi- 1999). Current descriptions and definitions of clin- vidual reality of knowing is mirrored not only in ical reasoning have been influenced by the diverse contemporary occupational therapy practice nature and goals of occupational therapy practice, (Yerxa 1991) but also in contemporary methods the philosophy of the profession itself, and the employed to study clinical reasoning which have various epistemologies of individual researchers. It moves the focus of reasoning away Occupational therapy was founded on humanis- from medical impairment by defining disability tic values (Meyer 1922, Slagle 1922, Yerxa 1991). Clients’ problems were viewed inal humanistic values on which the professional in terms of physical or psychiatric diagnosis thinking developed are seen in contemporary rather than occupational need (Spackman 1968). Clinical decision making became ability for all is conceptualized in this century as reductionistic, as evidenced by stated goals for an issue that is not simply the concern of people intervention which were aimed at improving with disabilities or those who are ill (Fawcett isolated units of function, such as particular 2000). The central and optimal occupational opportunities for all, concept of caring for self through a balanced thereby placing their reasoning within the realm sequence of activity found no place in the medical of public health. This day life in which ‘people can choose, organize type of reductionistic focus persists in a number and engage in meaningful occupations that of current clinical reasoning practices (Keilhofner enhance health, quality of life and equity in hous- & Nelson 1987, Neistadt & Crepeau 1998, Rogers ing, employment and other valued aspects of life’ & Masagatani 1982). Decision making focuses on Elements of contemporary views of procedural issues such as maintaining well-being through reasoning emerged and reflected the scientific occupation, enhancing people’s unique capacities influence of the time. Reilly (1960), for example, and potential, scaffolding occupational and social proposed an early model of clinical reasoning for support for all people and communities, and occupational therapy that was a type of procedural advocating for politically supported and social thinking process. Increasingly, using the formula: treatment plan equals the sum therapists are required to think about structural of the related raw data drawn from the data collect- social barriers in communities rather than beha- ing instruments of observation, testing, interview viours in individuals. During an everyday working arena for occupational the 1970s this formula became formalized into therapists, who must use their reasoning skills the assessment and treatment planning part of the to determine how occupational performance fits occupational therapy process. Day (1973), for example, During its early years, occupational therapy created a model of decision making with the com- quickly expanded its services to a variety of medi- ponents of problem identification, cause identifica- cal facilities. Although everyday occupations tion, treatment principle or assumption selection, remained the focus of therapy (Anderson & Bell activity selection and goal identification. The circu- 1988), there was an increased alliance to medical lar model created depended on generating and trends that focused on isolated cause-and-effect testing a series of hypotheses about client problems principles of illness. Growing pressure from medi- and reactions to intervention, and contributed to cine for a more scientific rationale for practice our understanding of procedural reasoning today (Licht 1947) resulted in specialized interventions (Bridge & Twible 1997, Dutton 1996, Rogers & where scientific explanations and medical parallels Holm 1991). Occupational the last decade has seen a resurgence of scien- therapists turned to kinesiologic, neurophysiologi- tific and reductionist thinking through the evi- cal and psychodynamic explanations of human dence-based practice movement (Taylor 2000).

Detector elements are effectively separated by Because selenium is used in its amorphous form 250mg mefenamic with visa muscle spasms 6 letters, large electric-field shaping within the selenium layer mefenamic 250 mg with amex muscle relaxer 800 mg. Charge-collection electrode Amorphous selenium has acceptable X-ray- design results in effective fill factors approaching detection properties and extremely high intrinsic 100% (see later) buy mefenamic 250 mg amex muscle relaxants knee pain. X-ray exposure order 250 mg mefenamic otc muscle relaxant vitamin, a homogeneous electrical charge (a More recent developments have produced full-field 5 kV bias voltage) is applied to the surface of the mammography systems using a-Se direct conversion selenium through an electrode layer. In the second detectors with a pixel pitch of 70 m and spatial res- olutions of 7. This has a high voltage power supply attached, which supplies a bias voltage via the top electrode layer before exposure. These phosphors are used rial borrowed from image intensifier technology as the image converter layer producing light when exposed to X-ray photons. The photodiode/phosphor layers replace the tured) lose some of the light energy by scattering. Visible X-ray photon interaction can spread to a number of light photons are then converted into an electric signal adjacent pixel sites, so reducing spatial resolution. The signal is shows commercially available fixed and portable cas- read out by activation of scanning control lines for settes using an indirect scintillator flat panel detector. The phosphor materials used for indirect- In order to reduce the problem of light scattering some conversion fall into two categories: manufacturers use structured scintillators developed Direct radiography (large area) 349 Table 12. This phosphor consists of doped cesium iodide crystals grown directly onto the detector. The structure consists of discrete and parallel monoclinic ‘needles’ of CsI:Tl, 5 (a) to 10 m wide and up to 600 m long. The crystals are highly hygroscopic (readily absorbing water vapor) and quickly degrade if not completely sealed. The monoclinic crystalline structure behaves in a similar manner to fiber-optic channels, steering light to the photodiode detector. Since light spreading is greatly reduced thicker layers of phosphor material can be used, increasing the number of X-ray photon inter- actions and thus the quantum efficiency. Evaluation and selection of a digital radi- ographic system should involve a thorough analysis of the complete imaging system, including the X-ray detector itself and the environment in which the sys- (c) tem will be used. In practice X-ray beams used in radiology quantum efficiency over the total range 40 to 100 kV are polyenergetic, so the quantum efficiency is while selenium shows a marked drop off in efficiency expressed as an ‘effective’ value covering the spec- for the higher photon energies. Quantum efficiency is generally the patient to be included on the same image highest at low energies, decreasing with increasing • the precision of X-ray signal to be measured in energy. Quantum efficiency increases markedly above the part of the image representing the most radio- any K edge. If, for example, there was a fac- tor of 50 in attenuation across the image field and it was desired to have 1% precision in measuring Table 12. Component Specification the dynamic range requirements for certain applica- Active area 43 43cm (17 17 ) tions may exceed the capabilities of available detectors. A theoretical range of 5 orders of Pixel pitch 143 m magnitude is given by both digital detector systems Element pitch 173 m as against the film-screen of 1 to 2 orders of magni- Fill factor 68% Spatial resolution 3. In practice the dynamic range for a digital Pixel depth 12 bit detector is restricted since a photon deficient, low Display time 10s exposure value (below 0. High doses are also possible without image degrada- 1 tion although patient high exposure levels are to be discouraged. As X-rays typical detector materials have already been given in are absorbed in the detector electrons and holes are Table 12. The entire selenium surface is available for X-ray charge conver- Digital radiography projection images originally used sion and, importantly, with properly designed charge storage phosphor imaging plates (see photostimula- collection electrodes, effective fill factors approaching ble phosphor plate). As already mentioned, limiting be taken in the design and manufacture of detectors spatial resolution is determined by the pixel spacing in to ensure that they provide uniform response. The frequency that characterizes this lim- digital system, the task is much easier, because, at iting resolution is known as the Nyquist frequency. It least over a considerable range, differences in response is simply the inverse of twice the pixel spacing. The sensitivity of magnification between the anatomical structure of any imaging system depends on photon absorption interest and the plane of the image receptor, photon. Factors that influence the acting X-ray to a more easily measurable form such intrinsic spatial resolution of the detector arise from as optical quanta or electric charge). Conversion its effective aperture size, spatial sampling interval efficiency can be expressed in terms of the energy between measurements and any lateral scattering Figure 12. Because indirect-conversion systems rely direct-detector system remains high up to this on light, substantial scatter occurs before the energy is Nyquist frequency. Digital radiography systems currently suffer from an inferior spatial resolution compared to film. Any digital imaging system that includes an antiscat- ter grid has the potential for interaction between the grid lines (i. For example, grid line artifacts often manifest in a ‘corduroy pattern’ of lines on the image owing to image aliasing: however, some high-strip-count grids do not leave apparent grid lines on digital images. Artifacts that can be produced by grid interaction are not always obvious and can (F) degrade image quality, so caution and proper selection of the grid are advised. Direct radiography (large area) 353 Assuming a certain photon flux incident on sharpness: however, excessive processing can lead to an the detector surface (Column A where N 100). The mean number of a useful quantity for characterizing the overall signal photons interacting at this stage represents the pri- and noise performance of imaging detectors. The passes through the imaging system from light produc- information available in the image is limited by the tion, signal transformation and image signal output. Columns C and D illustrate light photon cre- gest greater image quality, although the results should ation in the photodiode and the escape of light pho- be evaluated at all frequencies to estimate the ability tons from the phosphor. Here, light absorption, of the image to depict both small and large image scattering and reflection processes are important. Indirect technologies suffer other sources of residual charge into account; the result is an electronic added noise that are practically absent in direct detec- memory artifact. The brightness and lateral spread of the light event Rapid serial image acquisition, as in the case of 20 produced by an absorbed X-ray depends on the depth to 30 frames per second fluoroscopy, can lead to of interaction in the scintillator (similar to film intensi- image artifacts owing to X-ray induced residual charge fying screens). Like acteristics are no longer dependent on exposure con- photostimulable storage phosphors, selenium detec- ditions as in the case of film-screen imaging (contrast tors possess a very wide dynamic range; unlike stor- resolution), but they can now be influenced and opti- age phosphors, as mentioned before, selenium mized by post exposure image enhancement. Image detectors do not require stimulation for image read- processing algorithms can also improve the optical out, which eliminates a source of image noise and appearance of detail structures up to the nominal improves image quality. The spatial resolution is detector spatial resolution by using spatial filtering, comparable to that of storage phosphor systems; either edge enhancement or smoothing or a combi- however, the absence of light scattering in the detec- nation of both; image smoothing reduces image tor provides an improved sharpness impression. Electronic displays (soft-copy display) 355 Contrast of lung structure and the mediastinum unacceptable increased image noise.

Syndromes

  • Scoliosis
  • Arterial and venous duplex ultrasound of the abdomen examines blood vessels and blood flow in the abdominal area.
  • If you take pain relievers on most days, tell your doctor. You may need to be watched for side effects.
  • Tenderness when the joint is pressed
  • Receive cancer treatment or medicines that weaken their immune system
  • Dim and blurred blind spot in the center of vision

Dyspepsia may or may not be related to eat- cause dyspepsia include potassium supplements mefenamic 250mg low price spasms shown in mri, iron generic 250mg mefenamic otc muscle relaxant euphoria, ing meals 250mg mefenamic visa spasms mouth. The annual prevalence of recurrent dyspepsia antibiotics (especially macrolides buy mefenamic 500 mg without a prescription spasms near anus, sulfonamides, met- is approximately 25% over a 3- to 12-month period. If ronidazole), digitalis, corticosteroids, niacin, gem?- frequent heartburn is included in dyspeptic symptoms, brozil, narcotics, colchicine, quinidine, estrogens, and the prevalence exceeds 40%. Addi- carcinoma, and previous gastric surgery raise the sus- tional studies may include stool inspection for parasites, picion of gastric malignancy and should lead to prompt abdominal radiography (for obstruction, calci?cations), endoscopy. It is recommended that young patients with dyspepsia nonulcer dyspepsia, accounts for up to 60% of cases. Atypical gastroesophageal re- etiology of a minority of cases of chronic dyspepsia. A portant to identify because the treatment of this disorder 2- to 4-week trial of an antisecretory agent is recom- differs from the treatment of other causes of dyspepsia. Gastric or esophageal cancer is present in 2% of cases Endoscopy is recommended for all patients whose with dyspepsia. Biliary tract disease is a rare cause of symptoms persist or who relapse after empirical chronic dyspepsia. Patients who fail to respond to empiric therapeutic ap- exclusively relieved by defecation or associated with the proaches should also undergo endoscopy. These patients may respond to reassurance and if necessary a course of antisecretory or prokinetic therapy. If symptoms persist, other treatments may References include behavioral therapy, psychotherapy, or antide- Malfertheiner P, Megraud F, O’Morain C, et al. The effectiveness of endoscopy in the manage- ment of dyspepsia: a qualitative systematic review. American Gastro- dyspepsia (pain or discomfort and centered in the upper enterological Association medical position statement: evaluation of dyspepsia. Biopsies/treatments and/or histology Does the patient have panic based on endoscopic for H. In general, jaundice is not evident until serum biliru- patient’s history, physical examination, laboratory studies, bin concentration exceeds 3 mg/dl. Imaging studies are in- for the diagnosis of jaundice is recommended, which dicated to con?rm the presence or the absence of biliary should include a careful history, physical examination, and obstruction. Nuclear patients’ risks factors for intrinsic liver disease, active imaging of the biliary tree that measures hepatic uptake systemic and abdominal symptoms, medications (in- of radiolabeled derivatives of iminodiacetic acid (e. Even if the clinical suspicion for biliary obstruction is Physical examination may reveal clues toward a spe- thought to be low, evaluating liver parenchyma is as ci?c condition. For example, high fever or right upper important as excluding that remote possibility of biliary quadrant tenderness suggests cholangitis. Altogether, the sensitivity and spec- hypertension); and signs of chronic liver disease such i?city of these tests is 89%–100%. If there is no clinical evidence of biliary obstruction, laboratory studies include serum aspartate and alanine evaluation for underlying liver disease is mandatory. It is not possible to differentiate intrahepatic serum levels of iron, transferrin saturation and ferritin from extrahepatic cholestasis on the basis of the serum (for hemochromatosis), antimitochondrial antibodies(for level of alkaline phosphatase. Initial evaluation of hyperbilirubinemia should deter- smooth-muscle antibodies and serum electrophoresis mine whether the process is secondary to conjugated (for autoimmune hepatitis), and alpha-1-antitrypsin ac- (direct) or unconjugated (indirect) bilirubin predomi- tivity (alpha-1-antitrypsin de?ciency). In isolated and asymptomatic mild elevation of may be needed to con?rm a diagnosis if the previously unconjugated bilirubin, the patient should be evalu- mentioned serology testing is negative. Once a biliary obstruction is established, therapy is of bilirubin metabolism such as Gilbert’s or Crigler- directed toward the relief of the mechanical obstruc- Najjar syndrome, and medication-induced disorders tion. The optimal strategy depends abnormal levels of aminotransferases and/or alkaline on the location and the type of obstructing lesion. Yes F Therapeutic intervention Biliary tract obstruction No E Biochemical studies for specific a consideration? Sleisinger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, and Management. Increased liver chemistry in an asymptomatic physiology, Diagnosis, and Management. Cytology, tuberculosis smear and tes should be extensively questioned regarding risk factors culture, triglyceride, and bilirubin concentration for liver disease. Hence, prompt on the amount of ?uid present, technique, and clinical set- detection and treatment are very important. Approximately 1500 ml of Fluid loss and weight change are related directly to so- ?uid has to be present for ?ank dullness to be detected. Fluid restriction is not necessary in Ultrasound is helpful when physical examination is not treating patients with cirrhosis and ascites unless the de?nite. All patients with new-onset ascites should undergo ab- 100 mg and furosemide 40 mg. Abdominal paracentesis is the in increasing urinary sodium or decreasing body weight, most rapid and cost-effective method of diagnosing the the doses of both medications should be increased si- cause of ascites and determining whether ?uid is in- multaneously as needed at a 100:40 ratio (e. All patients with decompensated liver disease lactone 200 mg plus furosemide 80 mg, then 300 mg with ascites should undergo paracentesis to rule out plus 120 mg, and ?nally 400 mg plus 160 mg). In addition, all pa- large-volume paracentesis followed by diet and diuretic tients with fever, abdominal pain or tenderness, mental therapy is appropriate for patients with tense ascites. Peripheral leukocyto- be treated with sodium restriction and oral diuretics sis, acidosis, and worsening renal function are other rather than with serial paracentesis. Liver transplanta- indications to perform abdominal paracentesis in pa- tion should be considered in patients with cirrhosis and tients with ascites. Initial tests on ascitic ?uid include cell count and peritonitis is treated with tetracycline. The management of ascites in Intestinal and Liver Disease: Pathophysiology, Diagnosis, and Treat- cirrhosis: Report on Consensus Conference of the International Asci- ment. Gallstone disease is the most common cause; how- port its use to evaluate sphincter of Oddi function; ever, biliary parasites, infectious agents, blood clots, and however, this remain controversial. The pain may medicine studies is this setting varies widely and be confused with peptic ulcer disease, bowel obstruction, depends on the availability of biliary manometry (see pancreatitis, urinary calculi, diverticulitis, some metabolic section E) and should be individualized based on the disorders, or functional bowel disease. The absence of gallstones in the proper clinical setting asymptomatic gallbladder disease and biliary tract dilation (atypical symptoms and/or normal liver tests and pan- (following cholecystectomy) are very common and a failure creatic enzymes) should prompt the evaluation for of detection may lead to potentially harmful and ineffective nonbiliary cause such as peptic ulcer or functional interventions, including biliary endoscopy and surgery. The initial history should focus on the location, dura- clude peptic ulcer disease and gastroduodenal tumors, tion, and character of the symptoms as described ear- and a side-viewing endoscope should be used when lier. There is commonly a history of similar, although tumors of the major ampulla are suspected. Total bilirubin and aminotransferase levels sludge (microlithiasis), parasites, or biliary dyskinesia. When gallstones are detected on ultrasound within the tectomy) is seen in about 75% of those with choleclo- gallbladder and liver tests are signi?cantly elevated, cholithiasis. Other causes of pain, such as pancreatitis choledocholithiasis should be considered. If liver tests and nephrolithiasis, may also be detected during ultra- are falling and there are no signs of cholangitis, chole- sonography. Endoscopic biliary drainage for severe acute chol- effectively dissolve gallstones but is experimental and angitis.

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