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By E. Jack. University of Indianapolis.

For example generic red viagra 200 mg without a prescription, you might start by assuming 98 that the students had a stereotyped attitude cheap 200mg red viagra mastercard. You would then wish to move them away from this towards an attitude which demonstrated understanding and acceptance of other views. The advantage of this method is that it recognises that not all students will develop the desired attitude nor will they all necessarily start a course with the same attitudes. The way to express objectives using this approach is to state ‘Away from … (a particular attitude), towards … (a desirable attitude)’. Writing objectives is not simply a process of sitting, pen in hand, waiting for inspiration, although original thinking is certainly encouraged. Objectives will come from a careful consideration of the subject matter, what you and your colleagues know about the students, and about the subject. These include: an analysis of your own and colleagues’ knowledge, skills and attitudes; ways of thinking and problem-solving to be devel- oped; students’ interests, needs and characteristics; subject matter, as reflected in the published literature (especially in suitable textbooks); the needs of patients and the community; the requirements of professional certifying authorities; the objectives of the department or school. The answer depends on the purposes for which the objectives are to be used. In designing a course, the objectives will be more general than the objectives for a particular teaching session within the course. As objective writing can become tedious, trivial and time-consuming it is best to keep your objectives simple, unambiguous and broad enough to convey clearly your intentions. To illustrate from our own field of teaching, the objectives for a six-week clinical skills course, conducted for groups of 9-10 students, are shown below. Though quite broad, these objectives have proved detailed enough for course planning purposes and for making the intentions of the programme clear to students. If your orientation is primarily the transmission of content, it is likely that your teaching methods will be dominated by lectures, assigned reading of books and electronically 100 based materials, and set problem-solving exercises. If it is to be the intellectual and personal development of your students, small group teaching or individual tutorials and e-mail discussions are likely to play a more important role. Among the most important will be: ensuring that students engage in appropriate learning activities; your own expertise in using different methods; technical and financial resources to support the method you wish to use. Before leaving this subject we should like you to consider one important matter about choice of methods. Courses are often constructed in ways that reveal a growing complexity of subject matter. For example, early in the first year there may be an emphasis on basic principles and ideas. In later years, subject matter may be very much more complex and demanding. Yet, in our experience, the teaching methods often used in the later years do not generally demand higher levels of intellectual performance and personal involvement. The main types of teaching in medical education, such as lecturing, small group teaching and clinical teaching are dealt with in earlier chapters. Other possibilities include project work, peer teaching and a variety of technology-based techniques. In addition, it should be remembered that students undertake many learning activities in the absence of teaching and there is growing pressure for this to become more common. It is reasonable to make explicit in your objectives areas where you expect the students to work on their own. This particularly applies to knowledge objectives which might be achieved just as well indepen- dently in the library or by accessing the Web. It could also apply to some skill objectives where students might be expected to seek out relevant experience by themselves or in open access skills laboratories. The way in which this process has been followed through in the clinical skills course we have already introduced is demonstrated once again on the course planning chart (Figure 6. When planning this course we were aware that many students needed assistance with their basic 101 102 history-taking and physical examination skills.

Cross References Amblyopia; Cover tests; Diplopia; Exotropia; Heterotropia; Nystagmus Ewart Phenomenon This is the elevation of ptotic eyelid on swallowing discount red viagra 200 mg with amex, a synkinetic move- ment discount red viagra 200mg on line. The mechanism is said to be aberrant regeneration of fibers from the facial (VII) nerve to the oculomotor (III) nerve innervating the levator palpebrae superioris muscle. Cross References Ptosis; Synkinesia, Synkinesis Exophoria Exophoria is a variety of heterophoria in which there is a tendency for the visual axes to deviate outward (latent divergent strabismus). Clinically this may be observed in the cover-uncover test as an inward movement as the covered eye is uncovered. Exophoria may occur in individuals with myopia, and may be physiological in many subjects because of the alignment of the orbits. Cross References Cover tests; Esophoria; Heterophoria Exophthalmos Exophthalmos is forward displacement of the eyeball. Cross References Lid retraction; Proptosis Exotropia Exotropia is a variety of heterotropia in which there is manifest out- ward turning of the visual axis of an eye; the term is synonymous with divergent strabismus. It may be demonstrated using the cover test as an inward movement of the eye which is forced to assume fixation by occlusion of the other eye. When the medial rectus muscle is paralyzed, the eyes are exotropic (wall-eyed) on attempted lateral gaze toward the paralyzed side, and the images are crossed. Cross References Cover tests; Esotropia; Heterotropia Extensor Posturing - see DECEREBRATE RIGIDITY External Malleolar Sign - see CHADDOCK’S SIGN - 113 - E External Ophthalmoplegia External Ophthalmoplegia - see OPHTHALMOPARESIS, OPHTHALMOPLEGIA Extinction Extinction is the failure to respond to a novel or meaningful sensory stimulus on one side when a homologous stimulus is given simultane- ously to the contralateral side (i. It is important to show that the patient responds appropriately to each hand being touched individually, but then neglects one side when both are touched simultaneously. More subtle defects may be tested using simultaneous bilateral heterologous (asymmetrical) stimuli, although it has been shown that some normal individuals may show extinction in this situation. A motor form of extinction has been postulated, manifesting as increased limb akinesia when the contralateral limb is used simultane- ously. The presence of extinction is one of the behavioral manifestations of neglect, and most usually follows nondominant (right) hemisphere lesions. There is evidence for physiological interhemispheric rivalry or competition in detecting stimuli from both hemifields, which may account for the emergence of extinction following brain injury. Neural conse- quences of competing stimuli in both visual hemifields: a physiologi- cal basis for visual extinction. Annals of Neurology 2000; 47: 440-446 Cross References Akinesia; Hemiakinesia; Neglect; Visual extinction Extrapyramidal Signs - see PARKINSONISM Eyelid Apraxia Eyelid apraxia is an inability to open the eyelids at will, although they may open spontaneously at other times (i. The term has been criticized on the grounds that this may not always be a true “apraxia,” in which case the term “levator inhibition” may be preferred since the open eyelid position is normally maintained by tonic activity of the levator palpebrae superioris. Clinically there is no visible contraction of orbicularis oculi, which distinguishes eyelid apraxia from blepharospasm (however, perhaps paradoxically, the majority of cases of eyelid apraxia occur in association with ble- pharospasm). Electrophysiological studies do in fact show abnormal muscle contraction in the pre-tarsal portion of orbicularis oculi, which - 114 - Eyelid Apraxia E has prompted the suggestion that “focal eyelid dystonia” may be a more appropriate term. Although the phenomenon may occur in isolation, associations have been reported with: Progressive supranuclear palsy (Steele-Richardson-Olszewski syn- drome) Parkinson’s disease Huntington’s disease Multiple system atrophy MPTP intoxication Motor neurone disease Acute phase of nondominant hemisphere cerebrovascular event Wilson’s disease Neuroacanthocytosis. The precise neuroanatomical substrate is unknown but the associ- ation with basal ganglia disorders points to involvement of this region. The underlying mechanisms may be heterogeneous, including involun- tary inhibition of levator palpebrae superioris. Neurology 1997; 48: 1491-1494 Cross References Apraxia; Blepharospasm; Dystonia - 115 - F “Face-Hand Test” - see “Arm Drop” Facial Paresis Facial paresis, or prosopoplegia, may result from: ● central (upper motor neurone) lesions ● peripheral (lower motor neurone; facial (VII) nerve) lesions ● neuromuscular junction transmission disorders ● primary disease of muscle (i. A dissocia- tion between volitional and emotional facial movements may also occur. Emotional facial palsy refers to the absence of emotional facial movement but with preserved volitional movements, as may be seen with frontal lobe (especially non- dominant hemisphere) precentral lesions (as in abulia, Fisher’s sign) and in medial temporal lobe epilepsy with con- tralateral mesial temporal sclerosis. Volitional paresis with- out emotional paresis may occur when corticobulbar fibers are interrupted (precentral gyrus, internal capsule, cerebral peduncle, upper pons). Causes of upper motor neurone facial paresis include: Unilateral: Hemisphere infarct (with hemiparesis) Lacunar infarct (facio-brachial weakness, +/− dysphasia) Space occupying lesions: intrinsic tumor, metastasis, abscess Bilateral: Motor neurone disease Diffuse cerebrovascular disease Pontine infarct (locked-in syndrome) ● Lower motor neurone facial weakness (peripheral origin): If this is due to facial (VII) nerve palsy, it results in ipsilateral weakness of frontalis (cf. Clinically this produces: Drooping of the side of the face with loss of the nasolabial fold - 116 - Facial Paresis F Widening of the palpebral fissure with failure of lid closure (lagophthalmos) Eversion of the lower lid (ectropion) with excessive tearing (epiphora) Inability to raise the eyebrow, close the eye, frown, blow out the cheek, show the teeth, laugh, and whistle +/− dribbling of saliva from the paretic side of the mouth Depression of the corneal reflex (efferent limb of reflex arc affected) Speech alterations: softening of labials (p, b). Depending on the precise location of the facial nerve injury, there may also be paralysis of the stapedius muscle in the middle ear, causing sounds to seem abnormally loud (especially low tones: hyperacusis), and impairment of taste sensation on the anterior two-thirds of the tongue if the chorda tympani is affected (ageusia, hypogeusia). Lesions within the facial canal distal to the meatal segment cause both hyperacusis and ageusia; lesions in the facial canal between the nerve to stapedius and the chorda tympani cause ageusia but no hyperacusis; lesions distal to the chorda tympani cause neither ageusia nor hypera- cusis (i.

This will determine how much detail you need to include and how you express your message discount red viagra 200 mg without prescription. A comprehensive and relevant report will pro­ vide the reader with information that is both specific and in sufficient de­ tail to meet their needs discount red viagra 200 mg fast delivery. Avoid giving too much detail, as it will be difficult for the reader to identify the key messages. However, too brief a report may mean the reader will need to seek further information or, even worse, make a poor decision based on an inadequate account of the facts. Organisation All reports, regardless of their length, need some sort of structure. The sec­ tion above on the format of reports provides you with a basic framework. This will help you select and organise information into a cohesive account. You will need to decide on appropriate headings for subdividing the content of the main body of your report. Breaking text into smaller sec­ tions in this way assists the reader in assimilating large amounts of data. The reader is also able to use headings to quickly locate specific details. Another important consideration is the sequence in which you want information to appear in a report. Without a logical order the reader would be left struggling to work out the links between facts and figures. There are various ways of ordering material, including: LETTERS AND REPORTS 87 ° a temporal or chronological sequence (so past history would come before the current examination and future actions would come last) ° a developmental sequence (so information about early play would come before the development of spoken language) ° a clinical sequence (so diagnosis would come before information on intervention) ° background information to specific information (so sections about general information like education and living accommodation would come before the more specific details of an assessment). Gather your facts In the same way as you would prepare a letter, you need to gather all the relevant facts and figures for your report. This information may come from the results of investigations, progress notes in the personal health record or explanations from the client. Thoroughness in record keeping will ensure that the information you use is accurate, up to date and factual. A brainstorming technique is often useful if you are dealing with a large amount of information or if you need to address a difficult subject. Write the central idea, theme or issue in the middle of a large sheet of pa­ per. Note down ideas, opinions, facts and figures associated with the cen­ tral idea using one- or two-word phrases. Use lines and arrows to show how points link together, and to indicate the hierarchy of the information. Once you have covered all the areas, you can start to sort your data into cohesive groupings. Asking yourself questions is a useful way of focusing your thinking, for example, ‘How do I know this child is showing a delay in gross motor skills? Drafting your report Once you have gathered your information and organised it into a basic framework, you can start to prepare a draft. Writing a report is not just about what you say but also how you say it. Remember that the majority of reports will now be read by the client and the client’s family or carers (NHS Plan 2001). Try to phrase your re­ port in a way that is more accessible for a lay person with limited clinical or technical knowledge. One idea to get around this problem is to provide a summary writ­ ten specifically for the client (NHS Training Division 1994). Remember that the way in which the message is expressed often inad­ vertently conveys underlying attitudes. Look at this example: ‘Mother ini­ tially denied any concerns about his hearing, but then confessed that she thought he did have problems…’ These words imply some sort of negative judgement on the part of the report writer about the client. Check that your report is objective and your interpretations have a clear evidence base. When preparing your final draft, consider how you will present the re­ port.

Before the operative pro- cedure generic 200 mg red viagra otc, there should be no effusion generic 200 mg red viagra free shipping, a full range of motion, and good quadriceps and hamstring strength. Postoperative Goals Physiotherapy should begin the day of surgery if the final result is to be full range of motion, no effusion, and strength equal to the opposite side. The surgeon or physiotherapist should make any necessary alterations in this program. That means the quadriceps should be actively exercised when the joint is weight bearing. For the hamstring graft, there should be no active resisted knee flexion exercises for six weeks. This protocol may need to be modified according the type of fixation used and if additional surgery is performed to the MCL, LCL, or because of meniscal repair. Ambulation • The patient may be able to tolerate partial weight bearing with a Zimmer splint (Fig. Rehabilitation • The extension splint must be worn while sleeping (if patient is using CPM, the splint is removed) (Fig. Exercises and Activities • For the first few days the patient should rest, with the knee elevated on the CPM machine and Cryo-Cuff or ice pack used continuously. Ambulation • The patient may tolerate weight bearing with a Zimmer splint. Exercises and Activities • Passive knee extensions are performed with ice, and the heel on a block (Fig. Ambulation • The patient should tolerate full weight bearing with the extension splint or the functional DonJoy Brace. Exercises and Activities • Quadriceps exercises: Straight leg raising in supine (only if no quads lag). Ambulation • The patient should be full weight bearing without the splint, but should continue the functional brace when active. Exercises and Activities • Swimming: Add flutter kick at poolside or flutter board. Weeks 9 to 12 Goals • To increase functional activities • To improve muscle strength and endurance. Exercises and Activities • Progress power walking to walk/jog on level surface. Rehabilitation • Cybex isokinetic exercises may be started with antishear device. Exercises and Activities • Muscle strengthening exercises for both the quads and hamstrings can be done in the gym (Fig. Week 14+ Exercises and Activities • Light sport activities (cross-county skiing, curling, golf, ice skating) may be started only if there is no effusion and there is a full range of motion and 75% quad/ham strength ratio (85% for roller blading), a negative Lachman test, and physician approval (Fig 8. Months 6+ Exercises and Activities • Vigorous pivoting activities may be resumed if the reconstructed knee is 90% of the strength of the opposite knee. The use of the brace may be discontinued when the patient has confidence in the knee. Start figure-eight exer- cises with large, lazy eights and then decrease the eight in size and 152 8. Cross the left foot in front of and behind right foot for 10m and then reverse pattern and direction (repeat 5 to 10 times in each direction). Modifications to Protocol • ACL and LCL repairs: Avoid varus stress by wearing the protective functional brace for six months. Modifications to Protocol 153 • ACL and MCL repairs: Avoid valgus stress wearing the protective functional brace for six months. It is important to realize the potential problems: How to deal with them and how to avoid them. No one likes complications, but the surgeon who is prepared to deal with them will rise above the others. Remember, it is not if, but when, and how bad the complications will be. The format of the discussion will be to present the problem, give a solution to the problem, and finally offer a prevention for the problem.

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