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He believes that these factors are unimportant after a first seizure since they do not reliably diagnose a syndrome nor predict prognosis generic levitra plus 400 mg visa. Thus order levitra plus 400mg with amex, the emergency room evaluation for both febrile seizures and nonfebrile seizures need only be minimal. The EEGs are not needed after a febrile seizure, and probably will not be help- ful after a nonfebrile seizure. In every child a good history and physical as well as neurological examination are mandatory. The use of testing should be reserved for the unusual child with a suspicious history or physical examination. Management after a First Episode Although the guidelines for the evaluation of febrile and nonfebrile seizure differ, there is general agreement that no medication is needed after the first seizure of either type. However, a discussion and explanation of what happened and its meaning are always needed to calm the parent’s fears and misconceptions. Most first seizures will not recur with or without medication and this should be emphasized. Generalized tonic–clonic sei- zures are often associated with some tonic contractions of the chest and some cyano- sis. Observers often believe that the child will swallow her tongue, die, or suffer brain damage because of the lack of oxygen. None of these statements are true, but the medical system must explain that truth to the panic-stricken parents at the time the child is first seen. The parents were just as frightened as if it had been a seizure since they believed that it was a seizure and need just as much reassurance. The appropriate work-up should be done if necessary but the parents can be reas- sured, regardless of the nature of the event. They will be relieved that the episode was a seizure or anything else serious. Tell them that if it occurs again it will be critical for them to carefully observe the circumstances and the order in which things happen. Assure them that if a similar episode recurs their child will recover just as he has after this episode and with a better history you can rethink the diagnosis. The most 60 Freeman important role of the physician managing a child and the family after a first seizure is to provide appropriate information about what seizures are and what they are not. In particular, the following should be emphasized: Reassurance about swallowing the tongue, suffering hypoxic damage to the brain and dying should be given. Limitations on the activities of daily living, riding bikes, swimming are unreasonable even after a first seizure. Testing is necessary only if there is something alarming about the child’s history or the examination. If the child has a new neurological deficit, recent substantial head trauma with loss of consciousness or if there is evidence of progressive loss of motor or cognitive function, then the physician should consider if further testing would be helpful. What if the initial impression is incorrect and the event really was a seizure? Diagnosing epilepsy at the time of the first seizure is not necessarily a benefit to the parent or the child, since early treatment does not prevent further seizures or alter the long-term course. Neither diagnosing them early nor missing them until they are more clearly present will have much impact on the child’s outcome or life. Less testing is needed in the emergency room after a first afebrile seizure. Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, and Shinnar S. Report of the Quality Standards Subcommittee of the American Academy of Neurology, The Child Neurology Society, and the American Epilepsy Society. The role of emergent neuroimaging in children with new-onset afebrile seizures. Stroink H, van Donselaar CA, Geerts, AT, Peters AC, Brouwer OF, Arts WF. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice guideline: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: long-term treatment of the child with simple febrile seizures. Bergin Childrens Hospital, Department of Neurology, Boston, Massachusetts, U. INTRODUCTION Neonatal seizures may be the first sign of cerebral dysfunction in the newborn, and may alert the clinician to the presence of an underlying neurological injury, and=or possibly reversible systemic disorder. These symptomatic seizures represent the majority of seizures in the neonate, although epileptic syndromes, both benign and ‘‘malignant’’ may also present at this age. The precise incidence of neonatal seizures is unknown and estimates vary depending on a number of factors, including the retrospective or prospective nature of the data reported, the definition used to define a neonatal seizure, and the source of diagnostic information. Developmental immaturity influences many aspects of diagnosis, management, and prognosis of seizures in the newborn. For instance, clinical seizure patterns in the neonate reflect the ‘‘reduced connectivity’’ in the neonatal brain—with promi- nence of focal ictal characteristics, and rarity of generalized patterns of clinical seizures. Many physiological processes are immature, leading to altered drug hand- ling compared to older children, and the immature brain may be more susceptible to developmental effects of anticonvulsant medications. CLINICAL FEATURES Careful observation of the clinical characteristics of paroxysmal movements in the newborn allows differentiation of more or less concerning patterns.

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He forbids anyone other than Nelda to assist with his routine activ- ities or pick him up when he falls discount levitra plus 400 mg on line. Either I left him and felt bad about leaving him order levitra plus 400mg otc, or I’d stay in the room, too. Certainly, Tina DiNatale lamented being carried by Joe, apparently to save himself time. Like whenever we go to the mall, my wife will get out of the car and start walking toward the entrance. Sometimes I wish she would offer to help even though I’d refuse; it’s just nice to be offered. Clearly, such complaints carry risks, of appearing ungrateful, selfish, en- titled, although some are probably valid. She overcame her personal terrors—agoraphobia or fear of the outdoors—to accompany him to doctor’s appointments, vis- its with friends, and cross-country medical quests. Yet she needs time for herself: 98 / At Home—with Family and Friends I work at a women’s shelter that I don’t want to give up. I found that if I can’t keep doing these things, that I’m really going to get angry and bitter, and I don’t want to. After Tom’s retirement, the Nortons retreated to a stone bungalow on a bluff overlooking the northern Atlantic coast. Life now centers around Tom, but Nelda Norton had once kept time for herself. I showed him where the pots and pans were, where the cans were, the can opener. While I was gone, he was going to take his daughters out to dinner anyway. You have to have someone who will sit by your bed, so that when you wake up about three in the morning and say, ‘I cannot move my leg,’ they will move it for you. When he is out in the yard, I’m always wondering where he is, whether he’s fallen and hurt him- self. The second generally arrives later, with concerns about whether and how children should help out. Studies have examined families with dis- abled young children (Curry 1995; Olkin 1999, 92–111), but few have At Home—with Family and Friends / 99 looked at how chronic diseases and disability affect adult filial relation- ships. Society seemingly views fully functioning legs as essential prerequisites to meaningful parent- ing, despite scant evidence that children of disabled parents suffer (Olkin 1999). Public consternation reflects two erroneous expectations: unless fully ambulatory, parents cannot care effectively for children; and when parents fail (as seems inevitable), responsibility will devolve to the state. Given these concerns, mothers with mobility problems attract the greatest hostility; fathers presumably have wives who do what’s needed. Many women cannot even find physicians willing to counsel them on birth control, pregnancy, or childbirth (Fine and Asch 1988, 21). Six obstetricians turned away one woman wheelchair user before a seventh agreed to de- liver her baby. Most hurtful was the censure of her now-former best friend, who asserted that her pregnancy was selfish and she would “ruin” her child’s life. Her baby is now one year old, and she acknowledges the usual ups and downs of new parenthood. Certain progressive chronic diseases affecting mobility, like diabetes, do heighten pregnancy risks, for mother and child. Candy Stoops worried about how her newly diagnosed neurologic disease would affect her pregnancy. I said that I didn’t want to abort unless I absolutely had to—if it meant danger to the baby as well as me, we might consider it. My neurologist called a specialist in New York to talk it over, and he said, “Go for it! But my neurologist felt that we could keep things under control enough for 100 / At Home—with Family and Friends me to at least have this baby. Candy said she had “a natural delivery because they had no idea how I was going to react under anesthesia,” but then for seven years she took medications with significant side effects. She and her husband decided not to have other children, worried that it might worsen her disease. I wasn’t able to go bike riding with him or skating—my husband did that. Instead of working as she would have done, she stayed home with her boy. Admittedly, she couldn’t carry him, so when he was fourteen months old,“he could climb up and down the stairs because he had to. One woman feels badly that she cannot pick up and carry a child tugging at her sleeve. Another woman spends hours playing cards and board games with her children in lieu of trips to the playground. Bonnie Winfield was six when her thirty-year-old father, a third-generation dairy farmer, developed polio from a rare vaccine reaction. My parents didn’t really sit my brothers and me down—we were all under eight—and try to explain what is going on with Dad.

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Place time along the horizontal axis discount levitra plus 400mg visa, and activities on the vertical axis 400 mg levitra plus with visa. Mark the days along the horizontal axis, and the activities on the vertical axis. MANAGING YOUR TIME EFFECTIVELY 245 Use various styles of shading to represent different activities. For in­ stance, you can use solid shading to block out the days you are in work and cross-hatching for Saturday morning when you normally do your shop­ ping. This type of visual display is useful for highlighting any activities that impinge on other areas. Solid shading appearing during the weekend, for example, might indicate that work-related activities were extending beyond normal contractual hours. Other activities, like hobbies or seeing friends, are things that we do out of choice. Find more time Once you have completed your analysis you should have a very clear idea of how you are using your time. For instance, try ordering a home delivery of your groceries on the Internet. Doing a big monthly shop in this way will cut out travel and shopping time. You may have to enlist the help of children, partners or friends in doing some of the tasks that you would normally carry out. Is there something that you can put on hold un­ til you have completed your project? These will need to be further subdivided into subgoals and mini-targets. You may need to re-establish your priorities and organise your time accordingly. Active versus passive Sentences written in the active rather than the passive voice are more direct and give impact to a message. Compare ‘the boy cleaned the car’ (active) with ‘the car was cleaned by the boy’ (passive). An active sentence also gives a livelier tone to a piece of writing and tends to have fewer words. However, the use of some passive constructions is desirable to provide vari­ ety and interest for the reader. Pitfalls: ° the use of an informal writing style in a context that requires a formal approach (and vice-versa) ° writing a piece in a tone that is inappropriate to the context (for example, most women’s magazines like to take an upbeat approach to health issues) ° the use of too many passive constructions. Each piece of writing consists of several hierarchical layers of organisation. These range from how the overall piece is structured down to the arrange­ ment of an individual sentence. The whole is divided into three parts – the introduction, the middle and the end. These sentences are connected by one single idea or theme, which is expanded upon through­ out the paragraph. Within each sentence, words are arranged according to their relation­ ship to each other. For example, the verb, or doing word, is placed near to the person or thing to which it relates – so ‘The dog barked. For example, the following sentence contains two clauses: ‘The dog barked but the postman was not afraid. DETERMINING YOUR STYLE 249 ° The paragraph is overlong (usually because it contains more than one idea or theme). Each paragraph within a piece will relate both to the previous paragraph and to the forthcoming one. Link statements help to give continuity from one paragraph to an­ other. These sentences help explain to the reader what you are about to dis­ cuss in the new paragraph and its relationship to the previous discussion (French 1994). Some common ways are: Chronological – the order follows the sequence of events as they have hap­ pened in time. Here are some tips: ° Constantly refer back to your aims whilst writing and remove any sections that are not directly relevant to your purpose. The way that you write information can affect how interesting it is for the reader. Lots of long paragraphs are difficult to assimilate and tiring for the reader. On the other hand, several short ones will seem repetitive and monotonous. Use synonyms to add interest – so instead of repeatedly using personal health record, you can try ‘clinical notes’, ‘records’, ‘health records’ or ‘notes’. Compare the following lists: complete fill in achieve do maintain keep up compile put together 252 WRITING SKILLS IN PRACTICE Doctors whose communication skills are poor upset the clients. For ex­ ample: ° ‘imply’ (suggest) versus ‘infer’ (deduce) ° ‘practical’ (pragmatic) versus ‘practicable’ (feasible) ° ‘less’ (quantity) versus ‘fewer’ (number). General writing pitfalls Here are some common pitfalls that catch most writers out at some point. DETERMINING YOUR STYLE 253 Summary Points ° Find your style by using your natural ‘voice’ when writing. Revisions are far easier with many writing tasks au­ tomated, for example checking spelling and grammar, doing word counts. Computers with a modem also offer another mode of communication via e-mail and access to research material on the Internet.

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All of [the disabled women] resented being given help they did not need or want generic 400mg levitra plus mastercard. Fundamentals can remain unchanged purchase 400 mg levitra plus visa, es- 104 / At Home—with Family and Friends pecially with old friends. Sally Ann Jones said her many friends often for- get she is “handicapped” and suggest doing “something like skiing. Friends may not see people day in and day out, so they cannot appreci- ate fully the realities of limited mobility. A seventy-year-old woman with osteoarthritis observed, I had friends in Boston, and we used to walk all over the Back Bay. IfImeet friends outside and they want to stand and talk, it’s difficult. But I really miss walking, and I feel as though my friends in Boston per- haps don’t quite understand. Even though they know I have the arthritis, I don’t think they really understand. Charles Everest’s co-workers “would approach me,” recounted his wife, Doris, “and they would say, ‘What should I do when I see Charles in the lunch line? Certainly friends, acquaintances, and family sometimes don’t know what to say. Near the end of my first year of medical school, I was hospitalized briefly when I be- came completely unable to walk. Although I had tried keeping my situa- tion secret, a classmate I barely knew came to my bedside one night. I got from Boston to the Capitol by wheelchair-accessible taxi, airplane, and Washington’s subway, the Metro. Department of Health and Human Services building (which the sign points out) leads to a side entrance. Linking arms and hoping for safety in numbers offer scant protection against anxiety, fears, or cars when people walk slowly. About one quarter of the people with major walking difficulties live in poverty. Trash-strewn or poorly maintained walkways, physical isolation, fears of injury or violence present other barriers. Many people with mobility problems live alone and cannot easily find walking partners. The man’s wheelchair appears heavy, institutional, hard to self-propel, with no seat cushion or back support to maximize safety and comfort. This woman in a lightweight rigid-frame wheelchair has the upper body strength to self-propel; she also has curb cuts. Waiting at a corner with curb cuts but without clearly marked crosswalks, I hope—as always—that my scooter won’t fail and that the drivers will see me as I pass their way. Nonetheless it feels terrific to be on wheels, powered by batter- ies, after having had so much trouble walking. I am white, upper middle class, well educated, from a family of girls taught we could achieve whatever we wanted if we worked hard enough. I therefore didn’t recognize the warning signs until they almost literally knocked me over. As I noted in the preface, the uncertainty and physical consequences of MS consumed most of my psychic energy during my years at Harvard Medical School. And people’s reactions to the “me” they equated with MS were equally daunting. Though the medical school made necessary aca- demic accommodations (absolving me from staying up all night on clinical rotations, fearing that excessive fatigue could exacerbate MS), hints of trouble started immediately. During a critical clerkship, the chief resident peered around corners as I sat at nurses’ stations writing notes on patients. Later I learned that the clerkship director had requested his surveillance to confirm that yes, indeed, I was “working up” patients. An attending physi- cian had complained that I was lazy and not doing my job. Over the two years of clinical rotations, such episodes recurred count- less times. I didn’t fight back—I was bewildered and overwhelmed more than angry, and my immediate goal was slogging through. Why did the elite of this caring profession persist so doggedly in marginalizing and excluding me? Medical school is physically arduous: was my exclusion justified by some Darwin- ian imperative that only the physically “fittest” should become doctors? Even if it were, I was startled by the hospital leader’s pronouncement re- counted in the preface: “There are too many doctors in the country right now for us to worry about training handicapped physicians. One potential employer, an academic researcher, asserted, “Even if you work full-time, we couldn’t give you a full-time salary. Full-time here is eighty hours per week, and I’m sure you’d only work forty hours. I could hire you because I feel sorry for you; or I could not hire you because I don’t want to deal with your disease; or I could try pretending you’re not sick and look at your qualifications. Finally an influential friend from my Harvard School of Public Health days stepped in and pulled a few strings. With his generous recommenda- tion and assurances, Boston University hired me for a research job that, over the next six years, offered many opportunities.

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Nor should this diagnosis be assigned simply because someone has a mystery ail- ment that has not yet been identified order levitra plus 400 mg otc. In Gordon’s case cheap levitra plus 400 mg mastercard, his orthopedic sur- geon had studied much about this illness after the pioneering work that had been done by John Sarno, M. That, together with Gordon’s lifelong pattern of illnesses, pointed the physician in the direction of a somatization disorder diagnosis. Finally, Gordon’s history of sexual abuse coupled with his high func- tioning in all areas made his doctor wonder what Gordon did and still does with the rage and emotional pain that would be a natural by-product of his history of sexual abuse. That rage needed an outlet, and based on Gordon’s history, physical disorders may have been the only acceptable, albeit painful, way to release his rage. Famed psychotherapist Alice Miller, in her book Thou Shalt Not Be Aware: Society’s Betrayal of the Child summed it up this way: “The truth about our childhood is stored up in our body and although we can repress it, we can never alter it. Our intellect can be deceived, our feelings manip- ulated, our perceptions confused and our body tricked with medication. Of course, as we have said many times during the course of this book, it is easy for a doctor who does not have a diagnosis for your mystery mal- ady to say it’s “stress” or “in your mind,” but sometimes it really is. If you suspect you might have somatization disorder, do the modified version of Could Your Symptoms Be All (or Partly) in Your Mind? If you are truly looking for wellness, you must be willing to go deep within and ask yourself the “hard questions. Although there are countless books on them, childhood diseases are not always easily identifiable or diagnosable. Many children have mystery maladies, and the solutions to them must be sleuthed out in the same man- ner as for their adult counterparts. Some will require the participation of a pediatric pathologist to help you identify your child’s illness. Others are simply a matter of tracking the origin of symptoms and creating a detailed enough picture of the mys- tery malady that any pediatrician—or even you, the parent—can identify. Here’s how the Eight Steps to Self-Diagnosis helped in four cases: eleven-year-old Jessica, eight-year-old David, four-year-old Lourdes, and nine-year-old Justin, each of whom had a different condition. Because their caring and diligent parents and doctors worked through the Eight Steps, each of these children is now a diagnostic success story. Case Study: Jessica Jessica was a red-haired, freckle-faced sixth grader who loved school and especially loved playing the flute in music class. Around Thanksgiving and quite out of the blue, Jessica began to complain of joint pains and stiffness. Her symptoms were worse in the mornings and on some of those mornings, 187 Copyright © 2005 by Lynn Dannheisser and Jerry Rosenbaum. These days were random, but Jessica’s mom, Marsha, knew just how sick her daughter was when it also happened on music-class mornings. On those days, Jessica would sometimes remain in bed until midday when she finally felt well enough to get up. There was just one problem: by the time she arrived at the doctor’s office, Jessica appeared normal. Jessica must have visited her pediatrician six times over a two-month period, and each time her doctor could find no physical evidence of a prob- lem. Finally, he suggested a referral for what he called “attention-seeking behavior. Nevertheless, she followed the doctor’s suggestion and took her daughter to a mental health counselor “just in case. The other possible diagnosis he suggested was a “school phobia,” where a child complains of pains on the morning of or night before school and con- sequently has a poor attendance record. In these cases, the pains usually resolve after the school bus has left. He reported that he didn’t know the underlying reasons for this yet, which would require further sessions to determine. Marsha thought all of this was utter nonsense since her daugh- ter loved school and wouldn’t miss her flute classes unless she truly felt sick. So Marsha took Jessica to a new pediatrician who couldn’t find any- thing on physical examination either and suggested that perhaps the girl had growing pains—recurrent limb pains that occur during a growth spurt. When he explained these growing pains usually occurred at night, Jessica herself spoke up and told the doctor her pains were worse in the morning. The doctor commented that this would suggest an arthritic condition, but Does Your Child Have a Mystery Malady? He repeated her blood tests and they were consistent with the earlier findings. She began having spiking temperatures and joint swelling, different from the stiffness that was described earlier. These symptoms became very confusing: Jessica’s temperature might spike as high as 103°F, but it would always quickly return to normal again. The doctor found this to be extremely odd and suggested Marsha might not know how to take her daughter’s temperature. This was highly offensive to the concerned and responsible mother of three. She went to the drugstore anyway and purchased three different types of thermometers, including an expensive deluxe digital thermometer and an ear thermome- ter. All this was to no avail—Jessica’s temperature was indeed spiking and measured the same on all three thermometers. The second new symptom was a salmon-colored rash that appeared mostly on her chest whenever her fever spiked.

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