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Total of 500 CME credits accumulated and reported in the 10-year period prior to issuing the certificate; 3 clomid 100mg otc women's health clinic kadena. The Board will issue the new certificate after the expiration date on the original certificate effective clomid 25 mg womens health 48858. Further details and current information for the certification and recertification programs can be obtained by writing to the ABPMR or by visiting their website. Suite 674 Rochester, MN 55902-3092 Telephone: (507) 282-1776 ABPMR E-mail: office@abpmr. INTRODUCTION DEFINITION OF STROKE Sudden focal (sometimes global) neurologic deficit secondary to occlusion or rupture of blood vessels supplying the brain Symptoms > 24 hours = stroke Symptoms < 24 hours = transient ischemic attack (TIA) Reversible ischemic neurologic deficit (RIND) = (this term is no longer used) EPIDEMIOLOGY Stroke, after heart disease and cancer, is the third leading cause of death in the United States. RISK FACTORS (Stewart, 1999) Nonmodifiable: Age—single most important risk factor for stroke worldwide; after age 55, incidence increases for both males and females Risk more than doubles each decade after age 55 Sex ( male > female) Race ( African Americans 2× > whites > Asians) Family history (Hx) of stroke 1 2 STROKE Modifiable (treatable) risk factors: Hypertension—probably the most important modifiable risk factor for both ischemic and hemorrhagic stroke; increases risk by sevenfold History of TIA/prior stroke (~ 5% of patients with TIA will develop a completed stroke within 1 month if untreated) Heart disease (Dz. A = artery; CN = cranial nerve FIGURE 1–2 The Circle of Willis is a ferocious spider that lives in the brain. Note that he has a nose, angry eyebrows, two suckers, eyes that look outward, a crew cut, antennae, a fuzzy beard, 8 legs, a belly that, according to your point of view, is either thin (basilar artery) or fat (the pons, which lies from one end of the basilar artery to the other), two feelers on his rear legs, and male genitalia. It is evident that lower-limb motor strip is in anterior cerebral artery distribution while upper-extremity motor strip is sup- plied by middle cerebral artery. Most of the lateral aspect of the hemisphere is mainly supplied by the middle cerebral artery. The anterior cerebral artery supplies the medial aspect of the hemisphere from the lamina termi- nalis to the cuneus. The posterior cerebral artery supplies the posterior inferior surface of the temporal lobe and the visual cortex. STROKE 5 FIGURE 1–5 Major vascular territories are shown in this schematic drawing of a coronal section through the cerebral hemisphere at the level of the thalamus and the internal capsule. MCA, middle cerebral artery; ACA, anterior cerebral artery; PCA, posterior cerebral artery. May have embolism from extracranial arteries affected by stenosis or ulcer Embolic: 30% of all strokes Usually occurs during waking hours Deficit is immediate Seizures may occur at onset of stroke Cortical signs more frequent Most often embolus plugs one of the branches of the middle cerebral artery. An embolus may cause severe neurologic deficits that are temporary; symptoms resolve as the embolus fragments Presence of atrial fibrillation, history of recent myocardial infarction (MI) and occurrence of emboli to other regions of the body support Dx of cerebral embolism Suggested by history and by hemorrhagic infarction on CT (seen in 30% of patients with embolism) also by large low-density zone on CT encompassing entire territory of major cerebral artery or its main divisions Most commonly due to cardiac source: mural thrombi and platelet aggregates Chronic atrial fibrillation is the most common cause. Seen with myocardial infarction, cardiac aneurysm, cardiomyopathy, atrial myxoma, valvular heart disease (rheumatic, bacterial endocarditis, calcific aortic stenosis, mitral valve prolapse), sick sinus syndrome 75% of cardiogenic emboli go to brain Lacunar infarction: 20% of all strokes Lacunes are small (less than 15 mm) infarcts seen in the putamen, pons, thalamus, caudate, and internal capsule Due to occlusive arteriolar or small artery disease (occlusion of deep penetrating branches of large vessels) Occlusion occurs in small arteries of 50—200 m in diameter Strong correlation with hypertension (up to 81%); also associated with micro-atheroma, microembolism or rarely arteritis Onset may be abrupt or gradual; up to 30% develop slowly over or up to 36 hours CT shows lesion in about 2/3 of cases (MRI may be more sensitive) Relatively pure syndromes often (motor, sensory)—discussed below Absence of higher cortical function involvement (language, praxis, non-dominant hemi- sphere syndrome, vision) Neuroanatomic Location of Ischemic Stroke (Adams, 1997) 1. Anterior Circulation INTERNAL CAROTID ARTERY (ICA): (most variable syndrome): Occlusion occurs most fre- quently in the first part of the ICA immediately beyond the carotid bifurcation. Central retinal artery ischemia is very rare because of collateral supply 8 STROKE Cerebral infarction: Presentation of complete ICA occlusion variable, from no symptoms (if good collateral circulation exists) to severe, massive infarction on ACA and MCA dis- tribution. Failure of distal perfusion of internal carotid artery may involve all or part of the middle cerebral territory and, when the anterior communicating artery is small, the ipsi- lateral anterior cerebral artery. FIGURE 1–7 Arterial anatomy of major vessels on the right side carrying blood from the heart to the brain. MIDDLE CEREBRAL ARTERY (MCA): Occlusion occurs at stem of middle cerebral or at one of the two divisions of the artery in the sylvian sulcus. ANTERIOR CEREBRAL ARTERY (ACA) (Figure 1–9): If occlusion is at the stem of the anterior cerebral artery proximal to its connection with the anterior communicating artery ⇒ it is usually well tolerated because adequate collateral circulation comes from the artery of the opposite side If both anterior cerebral arteries arise from one stem ⇒ major disturbances occur with infarction occurring at the medial aspects of both cerebral hemispheres resulting in aphasia, paraplegia, incontinence and frontal lobe/personality dysfunction Occlusion of one anterior cerebral artery distal to anterior communicating artery results in: – Contralateral weakness and sensory loss, affecting mainly distal contralateral leg (foot/leg more affected than thigh) – Mild or no involvement of upper extremity 10 STROKE – Head and eyes may be deviated toward side of lesion acutely – Urinary incontinence with contralateral grasp reflex and paratonic rigidity may be present – May produce transcortical motor aphasia if left side is affected – Disturbances in gait and stance = gait apraxia FIGURE 1–9 The distribution of the anterior cerebral artery on the medial aspect of the cerebral hemisphere, showing principal regions of cerebral localization. Posterior Circulation: Vertebrobasilar Arteries & Posterior Cerebral Arteries POSTERIOR CEREBRAL ARTERY (PCA): Occlusion of PCA can produce a variety of clinical effects because both the upper brainstem and the inferior parts of the temporal lobe and the medial parts of the occipital lobe are sup- plied by it. Particular area of occlusion varies for PCA because anatomy varies 70% of times both PCAs arise from basilar artery; connected to internal carotids through posterior communicating artery 20%–25%: one PCA comes from basilar; one PCA comes from ICA 5%-–10%: both PCA arise from carotids Clinical presentation includes: Visual field cuts (including cortical blindness when bilateral) May have prosopagnosia (can’t read faces) palinopsia (abnormal recurring visual imagery) alexia (can’t read) transcortical sensory aphasia (loss of power to comprehend written or spoken words; patient can repeat) Structures supplied by the interpeduncular branches of the PCA include the oculo- motor cranial nerve (CN 3) and trochlear (CN 4) nuclei and nerves STROKE 11 Clinical syndromes caused by the occlusion of these branches include oculomotor palsy with contralateral hemiplegia = Weber’s syndrome (discussed below) and palsies of ver- tical gaze (trochlear nerve palsy) VERTEBROBASILAR SYSTEM: Vertebral and basilar arteries: supply midbrain, pons, medulla, cerebellum, and posterior and ventral aspects of the cerebral hemispheres (through the PCAs. At the pontomedullary junction, the two vertebral arteries join to form the basilar artery, which supplies branches to the pons and midbrain. Cerebellum is supplied by posterior-inferior cerebellar artery (PICA) from vertebral arteries, and by anterior-inferior cerebellar artery (AICA) and superior cerebellar artery, from basilar artery Vertebrobasilar system involvement may present any combination of the following signs/symptoms: vertigo, nystagmus, abnormalities of motor function often bilateral. Lateral Medullary (Wallenberg’s) Syndrome This syndrome is one of the most striking in neurology. Signs and symptoms include the following: – Ipsilateral side Horner’s syndrome (ptosis, anhydrosis, and miosis) decrease in pain and temperature sensation on the ipsilateral face cerebellar signs such as ataxia on ipsilateral extremities (patient falls to side of lesion) – Contralateral side Decreased pain and temperature on contralateral body – Dysphagia, dysarthria, hoarseness, paralysis of vocal cord – Vertigo; nausea and vomiting – Hiccups – Nystagmus, diplopia Note: No facial or extremity muscle weakness seen in this syndrome 12 STROKE II. Benedikt’s Syndrome (Red Nucleus/Tegmentum of Midbrain): Obstruction of interpeduncular branches of basilar or posterior cerebral artery or both Ipsilateral III nerve paralysis with mydriasis, contralateral hypesthesia (medial lemniscus), contralateral hyperkinesia (ataxia, tremor, chorea, athetosis) due to damage to red nucleus III. Syndromes of the ParamedianArea (Medial Brainstem): Paramedian area contains: Motor nuclei of CNs Cortico-spinal tract Medial lemniscus Cortico-bulbar tract Signs/symptoms include: contralateral hemiparalysis ipsilateral CN paralysis Location (grossly) of cranial nerve nuclei on brainstem * NOTE: nucleus of CN 1 and CN 2 located in forebrain.

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The sex of the child does not appear to affect the likelihood of physical abuse but other risk factors have been identified and these are summarised in Box 9 purchase clomid 25mg with mastercard womens health watch. Role of imaging Non-accidental injury (NAI) frequently presents via the Accident and Emergency department as either an occult injury or as a raised clinical suspicion due to unclear and inappropriate history or other suspicious signs7 (see Box 9 buy clomid 100 mg amex women's health issues forum. Physical injury: The actual or likely physical injury to a child, or failure to prevent physical injury (or suffering) to a child including deliberate poisoning, suffocation and Munchausen’s syndrome by proxy. Sexual abuse: The actual or likely sexual exploitation of a child or adolescent. Emotional abuse: The actual or likely adverse effect on the emotional and behav- ioural development of a child caused by persistent or severe emotional ill treat- ment or rejection. Neglect: The persistent or severe neglect of a child, or the failure to protect a child from exposure to any kind of danger, including cold and starvation, or extreme failure to carry out important aspects of care, resulting in the significant impairment of the child’s health or development, including non-organic failure to thrive. Parental pressure Premature baby/serious neonatal illness Handicapped child Failure to bond with baby/child Fretful/crying baby – difficult to console Environmental factors Young, immature/inexperienced parents Social deprivation/drug and alcohol abuse Lack of good parenting models (persistent cycle of abuse) Box 9. The role of imaging in the examination of NAI is: To demonstrate and date clinically suspected fractures To demonstrate and date clinically occult fractures8 194 Paediatric Radiography The skeletal survey is the main plain film examination undertaken when NAI is suspected but it is only appropriate for the examination of children under 2 years of age. Above this age, the use of alternative imaging strategies (MRI or scintigraphy) combined with confirmatory radiographic examination or selec- tive radiography of clinically suspicious regions is more appropriate8,9. Imaging requests for NAI skeletal surveys should only be accepted from a paediatric con- sultant, preferably following discussion with a radiologist10 as there is a large amount of inter-reliance between clinical and radiological evidence in the diag- nosis of NAI5. The skeletal survey examination should be performed during normal working hours when the appropriate radiological expertise is available as this will prevent any unnecessary delay in the reporting of the examination or the recall of patients for additional projections. Each clinical department should have a skeletal survey protocol for use in cases of suspected physical abuse and, although the purpose of the skeletal survey is always to identify suggestive and occult skeletal injuries in order to confirm a suspected NAI diagnosis, the number and type of radi- ographic projections undertaken as part of the survey are not consistent between hospitals within the UK. This local variation may be as a result of radiologist preference, research evidence or traditional practice, but whatever the reason for the inclusion or exclusion of projections, it is important to ensure that the benefit to the patient from the examination outweighs the detriment/harm of exposure to radiation. In addition it is the radiographer’s responsibility to ensure that the images produced are of optimum quality. Anatomical markers, patient details and examination date/time should all be clearly marked on the film as well as the initials of the examining radiographer(s)10. The child should be accompanied to the imaging department by either the guardian(s), who should Box 9. Antero-posterior/postero-anterior chest (to image clavicles, ribs and scapulae) Antero-posterior abdomen (to image spine and pelvis) Antero-posterior both upper limbs (shoulder to metacarpals) Antero-posterior both lower limbs (hip to tarsal bones) Lateral thoracolumbar spine (to include spinous processes) Lateral skull Non-accidental injury 195 be fully informed of the reasoning behind the imaging request, or a named nurse or social worker. It is important to remember that the role of the health care professional is not to ‘judge’ the patient or their families but to behave in a professional non-judgemental manner. Two radiographers (or radiographer plus assistant) should be present during the examination to act as witness to the proceedings10,11 and it has been argued that within each imaging department a radiographer with specific responsibility for undertaking NAI skeletal surveys should be identified in order to optimise the radiographic image quality11. Injury patterns Accidental injury to non-ambulant infants is uncommon but does occasionally occur and therefore all cases must be reviewed in light of the social and histor- ical evidence provided. For the majority of physically abused children there will 5 be radiological evidence of skeletal injury but cutaneous injuries, visible to the examining radiographer, may raise suspicions of physical abuse. Cutaneous injury Bruises of varying ages are commonly found on young mobile children, particularly on the forearms and anterior aspects of the lower limbs, and it is important to distinguish accidental bruising from abuse. Bruising is present in approximately 90% of physical abuse cases2 and the location, pattern, age and number of bruises can provide significant clues as to the likely cause of injury (Box 9. Finger tip bruises around the upper arms and chest wall suggest the child has been held tightly and therefore the possibility of the child being shaken must be considered12. Accidental bruising Forehead Chin Spinous processes Iliac crests Forearms Shins Inflicted bruising Ears Cheeks Neck Chest Abdomen Thighs Buttocks and genitalia 196 Paediatric Radiography Box 9. When considering bruising patterns and comparing the clinical history (time of injury) with the physical evidence, an awareness of the approximate age of bruises is important. However, the dating of bruises is not an exact science and variations occur between individual children (Box 9. Burns and scalds, although uncommonly seen within the radiology depart- ment, are worth mentioning in this section for completeness. Neglected children are more prone to accidental burns (either from hot liquids or dry, hot surfaces) and careful consideration of the clinical history is essential before physical abuse is diagnosed. Accidental burns and scalds have characteristic drip, pour and splash patterns whereas hands, feet or buttocks that have been immersed in scalding water will have a ‘glove’ or ‘stocking’ pattern. However, cigarette burns, although apparently synonymous with abuse within many texts, are in reality 12 uncommon injuries.

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Patients who have sustained a large burn injury require extensive custom positioning regimens order 50 mg clomid free shipping women's health clinic vancouver bc, that are closely monitored and altered as dictated by the their medical status order 100mg clomid with mastercard womens health institute peoria il. The key to preventing skin breakdown and pressure ulcers is to reposition the patient frequently. This alleviates excessive and prolonged pressure on certain anatomical locations. A written comprehensive positioning and shifting regimen with photographs should be posted in the patient’s room. The entire team along with the patient’s family should be educated on how to implement this positioning program. When the patient is medically stable he or she should be spending a lot of time in the upright position ambulating or sitting in a chair with frequent shifting, in order to minimize the risk of pressure ulcers on already compromised body surface areas. In the operating room (OR) the patient must be carefully positioned to accommo- date the physician’s needs and to prevent complications from incorrect positioning such as iatrogenic pressure sores and nerve palsies. The problems associated with handling a patient with burn wounds are always a concern. Most frequently, patients may be positioned supine, prone, sidelying or, in the cases of special operative proce- dures, they may be suspended by traction. Skeletal traction may be utilized intra- operatively for delicate skin grafting procedures during which shearing may dam- age or destroy the new skin or skin substitute applied. This can be achieved by hoisting the patient’s top four-corner traction frame up in the OR (Fig. The traction’s pulley system is disengaged and all four extremities are tied directly to the top frame. The therapist’s role is to monitor closely the forces exerted on the extremities during suspension and to fabricate a special head sling (Fig. No matter how positioning in the operating room is approached, the team should make sure that the patient’s entire body is positioned correctly and not focus only on the positioning of the operative site. After a skin grafting operation the patient may be placed on bed rest according to the unit’s immobilization protocol. Postoperative positioning is very similar to preoperative positioning, with the emphasis on protecting the newly applied develop in the hand that, if left untreated, may lead to devastating functional limitations. It leaves the hazards at the workplace, but attempts to diminish the effects on the worker (eg, job rotation or job enlargement). The performance of therapeutic exercise and activities to increase endurance. Endurance-type exercise that relies on oxidative metab- olism as the major source of energy production. Alexander technique: Movement education in which the student is taught to sit, stand, and move in ways that reduce physical stress on the body. American Journal of Physical Therapy: The official journal of the American Physical Therapy Association. It provides literature on physical therapy research, edu- cation, and practice. American National Standards Institute (ANSI): Clearinghouse and coordinating body for voluntary standards activity on the national level. American Society of Hand Therapists (ASHT): Established in 1978, the ASHT is concerned with hand rehabilitation education and research among practi- tioners in this area. The Journal of Hand Therapy is a publication resulting from the work of the ASHT. The amma tech- niques encompass myriad pressing, stroking, stretch- ing, and percussive manipulations with the thumbs, fingers, arms, elbows, knees, and feet on acupressure points along the body’s 14 major meridians. Some mild anal- gesics are nonsteroidal anti-inflammatory drugs (eg, Motrin [McNeil-PPC, Inc, Ft. It can either affect the whole body (eg, nitrous oxide, a general anesthetic) or a particular part of the body (eg, xylocaine, a local anesthetic). Massage therapy is contraindicated due to the potential for excessive bleeding. ANOVA (analysis of variance): Abbreviation for statis- tical method used in research to compare sample pop- ulations. A molecule produced by the immune system of the body in response to an antigen and which has the particular property of combining specifically with the antigen that induced its formation. Antibodies are produced by plasma cells to counteract specific antigens (infectious agents like viruses, bacte- ria, etc).

The Pain Anxiety Symptoms Scale: Develop- ment and validation of a scale to measure fear of pain purchase clomid 100 mg without prescription womens health organization. Generalized hypervigilance in fibro- myalgia: Evidence of perceptual amplification discount clomid 25 mg on-line womens health 2014. A survey of children’s acute, recurrent, and chronic pain: Validation of the pain experience interview. Behaviours care- givers use to determine pain in non-verbal, cognitively impaired individuals. Sex differences in thermal nociception and morphine antinociception in rodents depend on genotype. Culture and gender effects in pain beliefs and the prediction of pain tolerance. The effect of ethnicity on prescriptions for patient-controlled analgesia for post-operative pain. Pain amongst ethnic minority groups of South Asian origin in the United Kingdom: A review. The influence of culture on pain in Anglo and His- panic children with cancer. Journal of the American Academy of Child and Adolescent Psychia- try, 29, 642–647. Social variables affect phenotype in the neuroma model of neuropathic pain. The effects of patient sex and race on medical students’ ratings of quality of life. Sex differences in the perception of noxious experimental stimuli: A meta-analysis. Pain response in Chinese and non- Chinese Canadian infants: Is there a difference? Interactions of a history of migration with the course of pain disorder. Chronic low back pain patients around the world: Cross-cultural similarities and differences. Comparison of perception of angina pectoris during exercise testing in African-Americans versus Caucasians. Ethnic differences influ- ence care giver’s estimates of pain during labour. Abnormal sensitization and temporal summation of second pain (wind-up) in patients with fibromyalgia syndrome. Ethnic differences among housewives in psychophysical and skin potential responses to electric shock. Different approximations of the McGill Pain Questionnaire in the Norwegian language: A discussion of content validity. Ethnicity as a risk factor for inadequate emer- gency department analgesia. Pain, disability, and physical function- ing in subgroups of patients with fibromyalgia. Comparison of symptoms in Japanese and American depressed primary care patients. Gender role expecta- tions of pain: Relationship to experimental pain perception. Sensory decision theory and visual analogue scale indices predict status of chronic pain patients six months later. CHAPTER 7 Social Influences on Individual Differences in Responding to Pain Suzanne M. Mason Department of Psychology, University of Bath This chapter explores how individuals respond to pain in the context of the wider social and cultural environment.

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