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By R. Kayor. Walla Walla University.

Furthermore naprosyn 250mg line, most of the early and explained generic naprosyn 500mg visa, if possible generic naprosyn 250mg mastercard, and in which the resources and programs focused on restorative or rehabilitative goals strengths of the person are catalogued order naprosyn 250mg online, need for services (tertiary prevention) whereas many newer programs are assessed naprosyn 250 mg generic, and a coordinated care plan developed to focus aimed at primary and secondary prevention. Simultaneously, the overall health care system sionals rather than by one solitary clinician. As a result, has evolved in response to financial, technologic, and most of today’s CGA programs bear little resemblance cultural forces. Nevertheless, comprehensive geriatric assessment and then traces the reviewing the basic principles of CGA provides an under- evolution of the next generation of health service deliv- standing of both the evolution of this method of health ery innovations that are derived from CGA. Finally, I care delivery and the framework for CGA-like interven- speculate on the future of CGA-like interventions. Such team care recommendations; and (3) implementation of recom- requires a set of operating principles and governance. First among these principles is an process is to be successful at achieving health and func- understanding of the roles of each member of the team tional benefits. Within this broad conceptualization, CGA and mutual respect among the different professions. The has been implemented using many different models in team must also establish rules for process of care includ- various health care settings. Although such teams have been embraced in Most CGA programs have used some type of identifica- principle by health care systems, in practice they often tion (targeting) of high risk parents as a criterion for run counter to the training of health professionals. The purpose of such selection ticular, physicians have had little training in working with is to match health care resources to patient need. For health care teams, and their basic training emphasizes a example, it would be wasteful to have multiple health medical model. Rather, the intensive (and expensive) members evaluate all patients; whereas extended team resources needed to conduct CGA should be reserved for members are enlisted to evaluate patients on an "as- those who are at high risk of incurring adverse outcomes. Most frequently, the core team consists of Such targeting criteria have included: a physician (usually a geriatrician), a nurse (nurse prac- titioner or nurse clinical specialist), and a social worker. Frequently, the constituency of the team failure) is determined more by the local availability of profes- • Expected high health care utilization sionals with interest in CGA than by programmatic Each of these criteria has been shown to be effective in needs. However, none of extended team is gradually yielding to a strategy that these criteria are effective in identifying patients who relies on flexibility in team composition so that patients would benefit from all geriatric assessment and manage- are assessed by only those providers who are likely to ment programs. In this model, the only consistent ria should be matched to the type of assessment and member of the team would be the primary care provider. For example, Brief screens, as described in Chapter 17, might identify a geriatric evaluation and case management program which providers need to conduct further assessment and might focus on persons at high risk of health care uti- therapy. Conversely, a preventive program might rely patient briefly to determine whether a more in-depth solely on age (e. The overriding approach of this strategy is that each patient receives the only the amount of assessment that is necessary. Assessment and Development Regardless of the composition of the team, a key of Recommendations element is the training of the team. Such training should Once patients have been identified as being appropriate serve several purposes: (1) to ensure that team members for CGA, the traditional model of CGA invokes a team have an adequate understanding of the CGA process; (2) approach to assessment. Such teams are intended to to raise the level of expertise of team members in their improve quality and efficiency of care of needy older specific contribution to the team; (3) to develop standard persons by delegating responsibility to the health profes- approaches to problems that are commonly identified sionals who are most appropriate to provide each aspect through CGA; (4) to define areas of responsibility of indi- 18. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 197 vidual team members; and (5) to learn to work effectively The process of management of clinical disorders can as a team. When new members of the team are added, tations of such protocols have frequently met with con- they should receive the basic components of the initial siderable resistance or have been ignored in clinical team training. Nevertheless, common approaches to these If CGA is to be effective, the following six components problems that span across providers participating in the of the process of care must be addressed: CGA team are important to ensure that a similar inter- vention is being rendered to all patients. Implementation of the treatment plan In inpatient settings where the assessment team has 5. Monitoring response to the treatment plan primary care of the patient, generally implementation of 6. Revising the treatment plan as necessary recommendations is not a problem, provided that there The approach to gathering clinical data is changing.

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On the other hand order naprosyn 250mg fast delivery, all of the findings could be explained by something interfering with normal function of the right sciatic nerve order 500mg naprosyn mastercard, as commonly seen with TMS cheap naprosyn 500 mg mastercard. That nerve receives branches from spinal nerves lumbar 3 discount naprosyn 500mg online, lumbar 4 discount 250 mg naprosyn amex, lumbar 5, sacral 1 and sacral 2. Therefore, anything that disturbs the sciatic nerve may affect the parts of the leg supplied by any or all of those nerves, which was clearly the case with this patient. Her examination also revealed tenderness on pressure over The Traditional (Conventional) Diagnoses 103 all the muscles of the right buttock, which is where the sciatic nerve is located. This and other characteristic findings on physical testing established the diagnosis of TMS involving the right buttock and sciatic nerve; the herniated disc was an incidental finding of no significance. Such clinical discrepancies are common and make one wonder why they are not routinely discovered. So fixed are physicians on the herniated disc, the diagnosis is sometimes made solely on the basis of a history of simultaneous low back, buttock and leg pain, or even in the absence of leg pain, without benefit of a CT scan or MRI study. The diagnosis of herniated disc cannot be made clinically or even with plain X rays. If the latter are done, what is usually seen is narrowing of an intervertebral disc space, most frequently of the last two intervertebral spaces. At the last space this abnormality is almost universal beyond the age of twenty, as stated earlier. It means the disc has degenerated, and it is a perfectly normal part of the aging process. It may be tempting but is inadvisable to attribute symptoms to normal aging phenomena. In my experience, disc degeneration is no more pathological than graying hair or wrinkling skin. In recent years there have been numerous reports in the medical literature of herniated discs in patients with no history of back pain. They were discovered inadvertently on CT or MRI studies done to investigate other parts of the body. In fairness to an objective evaluation of the problem, it should be noted that in one statistical study there was a higher incidence of back pain historically in people with evidence of disc abnormalities. I have tried to reconcile this with the clear observation that it is TMS and not disc pathology that causes the pain and can only conclude that in the mysterious process by which the brain chooses a site for TMS it selects an area of “abnormality” (like disc herniation) even though the anatomical aberration may not be pathological. One hundred and nine patients were interviewed by telephone by a research assistant. Their names were selected randomly from a large population of patients who were seen and treated from one to three years previously. In each case pain was attributed to a herniated disc that could be seen on CT scan. Based on history and physical examination, the diagnosis was TMS; all went through the usual treatment program. The results were as follows: Free, or nearly free of pain, unrestricted physical activity................................... Yet each of these patients had been told that this was the reason for the pain; thirty-nine had been advised to have surgery; three had already had such surgery; and most of the rest had been told that surgery might be necessary if conservative measures failed. The patient was a twenty-five- year-old man with a history of low back and right leg pain; he had had a lumbar myelogram showing a herniated disc two months before I saw him in consultation. He was advised to stop all physical activity and surgery was recommended, both appropriate recommendations if the disc was the cause of the pain. A dedicated athlete (basketball and squash were his favorites), he was devastated by the diagnosis. He was further upset by the fact that he would no longer be able to “burn off” his tension through vigorous sports, and he saw himself as a very tense fellow. The Traditional (Conventional) Diagnoses 105 He decided against surgery and, with great trepidation, continued to work out in the gymnasium; he even played basketball occasionally. Though he got neither better nor worse, he lived in constant fear that he might really hurt himself. My examination disclosed no evidence of nerve damage in either leg; the straight leg–raising test on both sides caused pain in the right buttock. As usual with TMS there was pain on manual pressure over the muscles of both buttocks, the small of the back on both sides, the top of both shoulders and the sides of the neck. He accepted the diagnosis, participated in the treatment program and was free of pain in a few weeks.

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Did it once supply the pineal The oculomotor (III) purchase naprosyn 500 mg with amex, trochlear (IV) and abducens (VI) nerves 123 Trochlear nucleus Fibres decussate before emerging from dorsal aspect of midbrain To superior oblique Superior orbital fissure IV passes in lateral wall of cavernous sinus Fig discount 250 mg naprosyn free shipping. Note: trochlear nerve is so called because superior oblique (which it supplies) is arranged as a pulley (Latin: trochlea – pulley) buy 250mg naprosyn with amex. Ascends to pass through cavernous sinus cheap naprosyn 500 mg visa, on internal carotid artery generic naprosyn 250 mg with amex, superior orbital fissure (within common tendinous ring). Motor fibres innervating them, therefore, are somatic motor fibres and nuclei are somatic motor nuclei. Parasympathetic fibres in III: Edinger–Westphal nucleus Edinger–Westphal nucleus on rostral margin of III nucleus. Receives fibres from superior colliculi and pretectal nuclei (ocular reflexes, The oculomotor (III), trochlear (IV) and abducens (VI) nerves 125 Chapter 22). Postganglionic axons in short ciliary nerves to constrictor pupillae and ciliary muscles. Benedikt’s syn- drome involves the nerve as it passes through the red nucleus: oculomotor paralysis with contralateral extrapyramidal dyskine- sia. In Weber’s syndrome the lesion is more ventral, also involving motor fibres in the cerebral peduncles: oculomotor paralysis is associated with contralateral UMNLs. Complete section of the oculomotor nerve would lead to ptosis (partial paralysis of LPS), lateral squint (unopposed action of superior oblique and lateral rectus), pupillary dilatation (unopposed sympathetic activity), loss of accommodation and light reflexes. This causes medial squint (somatic fibres) and ptosis (sympathetic fibres to LPS). It may be involved in fractures of the base of the skull or in intracranial disease. Section of the nerve would result in con- vergent squint (the eye abductor being paralyzed). Because of this long intracranial course it is often the first cra- nial nerve to be affected by intracranial disease. So, if you could only test one cranial nerve as part of a neurological investiga- tion, this would be the one! This compresses the midbrain which passes through the tentorial notch and the nearby oculomotor nerve. The result is pupillary dilatation (unopposed sympathetic action as the parasympa- thetic fibres in III are affected), at first unilateral and then bilat- eral. Because this may cause an erroneous diagnosis to be made, it is known as a false localizing sign. It affects all the nerves that pass through or in the wall of the sinus (III, IV,Va,VI). The abducens nerve is usually affected first because it passes through the sinus, causing a paralysis of lateral rectus and a resultant medial squint. Involvement of the ophthalmic nerve may cause severe pain, and the condition may result ultimately in papilloedema and visual loss. Since the advent of antibiotic therapy, this con- dition is much less often encountered than formerly. Chapter 22 VISUAL REFLEXES: THE CONTROL OF EYE MOVEMENTS; CLINICAL TESTING OF II, III, IV AND VI 22. This reflex is elicited on patients, conscious or unconscious, and it is, amongst other things, a crude test of brain stem function. Pass down left hand side, along bottom and up right hand side Postganglionic fibres Shine light in ciliary nerves to in eye constrictor pupillae Ciliary ganglion Preganglionic fibres in III Impulses pass along optic nerve, chiasma, tract Before reaching lateral geniculate Edinger–Westphal body, some fibres nucleus branch to midbrain Midbrain pretectal nucleus Fig. Pupillary light reflex Accommodation reflex Retina Retina Optic nerve Optic nerve Optic chiasma Optic chiasma Optic tract, then branching Optic tract, lateral geniculate fibres to: body, optic radiation, visual cortex, association fibres to frontal lobes, fibres descend through anterior limb of internal capsule to: Midbrain: pretectal nuclei Midbrain: superior colliculus Midbrain: Edinger–Westphal Midbrain: Edinger–Westphal nucleus then ipsi- and nucleus then ipsi- and contralateral to: contralateral to: Oculomotor nerve III Oculomotor nerve III Ciliary ganglion (synapse) Ciliary ganglion (synapse) Constrictor pupillae muscle Muscles of iris and ciliary body for miosis commissural connections, when light is shone into one eye, both pupils respond: the reflex is consensual. Fixed dilated pupils are pupils which do not respond to light: they are a likely indi- cator of brain death. These changes are 130 Vision, eye movements, hearing and balance equivalent to those made by photographers in stop adjustment and lens extension on a camera. You will realize that in the accommoda- tion reflex perception is involved, unlike the pupillary light reflex, and thus the cortex is involved. There is also a degree of voluntary control since you can decide to focus on an object. A comparison of the pathways for the accom- modation reflex, which functions normally, and the pupillary light reflex, which does not, indicates that the lesion could be in: (a) the fibres that pass from the optic tract to the midbrain, (b) the pretec- tal nuclei or (c) that part of the Edinger–Westphal nucleus which deals with fibres from the pretectal nuclei. The frontal eye fields mediate voluntary eye movements and are responsible for saccadic movements by which means we search the visual fields for an object on which to fix. Saccades are so rapid that individual visual images are imperceptible until fixation has ensued.

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