"Generic 25 mg sinequan, anxiety symptoms quiz".

J. Esiel, M.A., M.D., M.P.H.

Assistant Professor, Hackensack Meridian School of Medicine at Seton Hall University

Key features of assessment tools Reliability: reflects the reproducibility of the assessment tool and the accuracy with which a score is being measured. It is higher in written assessments such as multiple choice and extended matching question formats, and lower in clinical competency-based assessments where there are more uncontrolled variables. Evaluation using generalisability theory can be performed to account for complex variables. Validity: reflects the accuracy with which a test measures what it is purported to measure. It is a qualitative factor that evaluates the authenticity of an assessment and its fitness for purpose. Educational impact: assessment is an important driver of learning; appropriate assessment tools encourage learners to acquire the desired knowledge, skills and attitudes. Cost-effectiveness: reflects the practical aspects of assessment and helps determine the choice of assessment tool. Acceptability: successful assessment formats must be acceptable to the teaching faculty and the learners. Blueprinting: ensures the assessment tool samples content across the full range of learning objectives for the curriculum. Assessment 67 Standard setting Numerous methods to determine pass-marks for different assessment formats are available. Norm-referencing: in norm-referenced assessments the pass mark is determined by examiners using comparison within the cohort of examinees and thus the pass-mark varies at each sitting. A percentage of candidates will pass the assessment on each occasion (Fixed Percentage Method). Norm-referencing does not take account of the content of the assessment or the competence of the candidates. Criterion-referencing: in criterion-referenced assessments the pass-mark is set in advance by a team of experienced examiners using their judgement about the degree of difficulty of the assessment and the minimum score expected of a candidate who just reaches the acceptable standard. A number of criterionreferenced standard setting methods are described including the Angoff and Ebel procedures. Good practice for summative assessments in medical education demands that a minimum competence (safety) level should be set ­ the assessment should identify the Pass/Fail border and all candidates who reach the required standard should pass the examination. Assessments should thus be criterion-referenced by experienced examiners who recognise the standard required of the candidates at whatever level of undergraduate or postgraduate experience. In addition, the examiner awards the candidate a global score, based on an overall judgement of performance. These methods have gained credibility as they allow experienced clinicians to make judgements about professional competence and they are currently the gold-standard methods for assessments of clinical competence. Assessments in medical education fall into three main categories ­ those that measure knowledge, competence and performance. Checks sensation starting distally with joint position sense, then light touch, pin prick 11. Checks for walking in lower limb examination and prontor drift in upper limb examination 12. Examines patient in a professional manner (gentle, watches for pain, maintains dignity and privacy) 14. Closure (thanks patient, leaves patient comfortable) Examiner to ask: "Please summarise your key findings" 15. Candidate presents summary in a fluent, logical manner "What do you think is the most likely diagnosis? Good news Bad news Neither Management Please mark one of the circles for each component of the exercise on a scale of 1 (extremely poor) to 9 (extremely good). A score of 1­3 is considered unsatisfactory, 4­6 satisfactory and 7­9 is considered above that expected, for a trainee at the same stage of training and level of experience. Please note that your scoring should reflect the performance of the SpR against that which you would reasonably expect at their stage of training and level of experience. You must justify each score of 1­3 with at least one explanation/example in the comments box, failure to do so will invalidate the assessment.

The genetic basis of this variability has been studied in detail using a mouse model, and several strains have been found to be either susceptible or resistant to noise-induced damage. The risk is likely an interaction between genetic susceptibility and the duration and intensity of the noise exposure (Figure 58­3). The most common complaint is difficulty in comprehending speech, especially in the presence of competing background noise. Background noise, which is usually low frequency in bias, masks the better-preserved portion of the hearing spectrum and further exacerbates problems with speech comprehension. Large studies have shown that the combined effect is additive over time, and attempts have been made to quantify this interaction. Estimated noise-induced threshold shift as a function of frequency, for various durations of exposure. Fine structure of long-term changes in the cochlear nucleus after acoustic overstimulation: chronic degeneration and new growth of synaptic endings. Differential vulnerability of basal and apical hair cells is based on intrinsic susceptibility to free radicals. It suggests that basal outer hair cells may be more susceptible to free-radical damage. This often requires a team consisting of otolaryngology, audiology, and audiologic engineers. After the diagnosis has been established by otologic examination and by the administration of an audiometric test battery, the physician should counsel the patient on the likely consequences of continued exposure to excessive noise, including recommending techniques for avoiding further noise-induced damage. Hearing amplification is reserved for patients whose hearing impairment is severe in social situations. Hearing aids must be carefully fitted to optimally meet the needs of the individual with regard to frequency bias and gain. In bilateral hearing losses, bilateral amplification usually provides more satisfactory rehabilitation. There are some instances in which hearing aids may be recommended to assist the patient to hear in special circumstances, such as lectures or group situations. In patients with high-frequency hearing loss and relatively normal low-frequency hearing, hearing aids are generally the most helpful to those who have a significant hearing loss at 2000 Hz on a pure-tone audiogram. A borderline candidate may be a person with normal hearing through 1500 Hz, a mild hearing loss at 2000 Hz, and a moderate or greater hearing loss at 3000 Hz and above. The two basic hearing aids that are available are the analog hearing aid and the newer, more expensive digitally programmable hearing aids. Before purchasing hearing aids, the patient should have a hearing aid evaluation and a trial period, with the patient wearing the aids in various circumstances. With no further inner ear injury, tinnitus gradually diminishes, usually over a course of weeks to months. A subtle degree of tinnitus often persists and is especially obvious when the patient is in a quiet room. For the few patients who find this to be extremely troublesome, masking the tinnitus with music or some other form of pleasant sound is often helpful. In those with significant hearing loss, the most successful treatment may be appropriate hearing amplification. Modified hearing aids (tinnitus maskers) designed to produce masking noises have generally been of limited success. Patients should be informed of various support groups available and psychiatric referral may be necessary to medically manage associated depression and anxiety. If there has been further progression of hearing loss after a person has been removed from the source of noise, the progression of further hearing loss is the result of some other degenerative, congenital, or metabolic process (eg, presbycusis). An effective hearing conservation program integrates the following program elements: (1) noise monitoring, (2) engineering controls, (3) administrative controls, (4) worker education, (5) selection and use of hearing protection devices, and (6) periodic audiometric evaluations. A sampling strategy must be designed to identify all workers who need to be included in the hearing conservation program. Using the appropriate noise- monitoring instrumentation, noise must be characterized in terms of the following: (1) frequency (predominantly high, predominantly low, or mixed); (2) intensity (how loud the sound is); and (3) type (continuous, intermittent, or impulse). Any time there is a change in production, the process, equipment, or controls, noise monitoring must be repeated. Engineering controls-The information collected during noise monitoring-particularly octave band analysis, which indicates the sound level at selected frequencies- may be used to design engineering controls.

Transition from Intravenous to Subcutaneous Insulin When transitioning from intravenous to subcutaneous insulin, it is generally recommended that an initial subcutaneous basal insulin dose of long- or intermediate-acting insulin be given prior to discontinuation of the intravenous insulin (Furnary, 2006). Based on the absorption profiles of longer-acting insulins, administering the first subcutaneous insulin dose two hours prior to stopping the insulin infusion would appear to Return to Algorithm Return to Table of Contents Determination of the initial basal insulin dose can be made using the guidelines above. An alternative method that has been suggested is to estimate the initial basal dose based on the intravenous insulin requirements over a six- to eight-hour period leading up to the transition time. Ideally, this six- to eight-hour period would be a time when the patient was not eating and was not receiving intravenous glucose. The initial basal insulin dose could be calculated as 80% of the estimated 24-hour insulin requirement to provide a margin of safety (Furnary, 2006). Example: A patient managed on an intravenous insulin drip is to be transitioned to subcutaneous insulin. Over a recent six-hour period when the patient was not eating and was not receiving intravenous glucose, the patient received a total of 15 units of insulin via the infusion. Example: Using the example above, the clinician plans to give 48 units of Glargine insulin at bedtime as the basal insulin dose on the transition to subcutaneous insulin. However, the clinician would like to transition the patient to subcutaneous insulin during the day rather than waiting until later in the evening when fewer staff are present. This intermediate-acting insulin would provide temporary basal insulin coverage until bedtime, when the 48 units of Glargine insulin could be given. This insulin would then be given in addition to the basal insulin in accordance with the order set. Medication adherence Non-adherence with medications can limit the success of therapy and help to explain why a patient is not achieving treatment goals. To screen for non-adherence, clinicians can ask patients open-ended, non-threatening questions at each office visit. The assessment should include probes for factors that can contribute to non-adherence (fear of adverse reactions, misunderstanding of chronic disease treatment, depression, cognitive impairment, complex dosing regimens or financial constraints). Interventions may include simplifying the medication regimen, using reminder systems, involving family or caregivers in care, involving multiple disciplines in team care, providing written and verbal medication Return to Algorithm Return to Table of Contents Depression evaluation There is a substantial increase in the prevalence of depression among people with diabetes as compared to the general adult population (Anderson, 2001). Depression impacts the ability of a person with diabetes to achieve blood glucose control, which in turn impacts the rate of development of diabetes complications (de Groot, 2001; Lustman, 2001). Identification and management of depression are important aspects of diabetes care. Intervention studies have demonstrated that when depression is treated, both quality of life and glycemic control improve. Counseling may be effective, especially among those who are having difficulty adjusting to the diagnosis of diabetes or are having difficulty living with diabetes. Clinicians should be cognizant of potential obstructive sleep apnea, especially among obese patients (Foster, 2009a; Foster, 2009b). Referral to an Extended Care Team Diabetes educator Consultation with a diabetes educator is suggested if the patient is having difficulty adhering to a nutrition, exercise and medication regimen, and the patient is having difficulty adhering to or accurately completing blood glucose monitoring or may need answers to his/her questions. Primary care clinician should develop a relationship with a diabetes education program to provide other options for management. The American Diabetes Association publishes a list of recognized educational programs in each state. These programs may be staffed with endocrinologists or primary care clinicians plus diabetes educators including dietitians, nurses and other health care clinicians who are Certified Diabetes Educators or have didactic and experiential expertise in diabetes care and education. Consultation with a specialist is suggested if persistent proteinuria, worsening microalbuminuria and elevation in serum creatinine or blood urea nitrogen, or hypertension unresponsive to treatment is seen. Endocrinologist/neurologist Consultation with a specialist is suggested if neuropathy progresses and becomes disabling. Endocrinologist/cardiologist/hypertension specialist Consultation with a specialist is suggested if blood pressure is refractory to treatment, or the patient has marked associated postural hypotension or symptoms of coronary artery disease. Opthalmology/optometry Retinopathy is estimated to take at least five years to develop after the onset of hyperglycemia begins.

Treatment: the disorder is treated with antibiotic eyedrops and ointments according to the specific pathogens detected in cytologic smears. Symptoms and diagnostic considerations: Usually the tumors cause unilateral painless swelling followed by dacryostenosis. Diagnostic considerations: the irregular and occasionally bizarre form of the structure in radiographic contrast studies is typical. Differential diagnosis: Chronic dacryocystitis (see above), mucocele of the ethmoid cells. Epidemiology: Keratoconjunctivitis sicca as a result of dry eyes is one of the most common eye problems between the ages of 40 and 50. As a result of hormonal changes in menopause, women are far more frequently affected (86%) than men. There are also indications that keratoconjunctivitis sicca is more prevalent in regions with higher levels of environmental pollution. The composition of the tear film can alter due to vitamin A deficiency, medications (such as oral contraceptives and retinoids), or certain environmental influences (such as nicotine, smog, or air conditioning). Symptoms: Patients complain of burning, reddened eyes, and excessive lacrimation (reflex lacrimation) from only slight environmental causes such as wind, cold, low humidity, or reading for an extended period of time. Diagnostic considerations: Often there is a discrepancy between the minimal clinical findings that the ophthalmologist can establish and the intense symptoms reported by the patient. Results from Schirmer tear testing usually show reductions of the watery component of tears, and the tear break-up time (which provides information about the mucin content of the tear film which is important for its stability) is reduced. Values of at least 10 seconds are normal; the tear break-up time in keratoconjunctivitis sicca is less than 5 seconds. Slit lamp examination will reveal dilated conjunctival vessels and minimal pericorneal injection. A tear film meniscus cannot be demonstrated on the lower eyelid margin, and the lower eyelid will push the conjunctiva along in folds in front of it. In less severe cases the eye will only be reddened, although application of fluorescein dye will reveal corneal lesions (superficial punctate keratitis; see p. Treatment: Depending on the severity of findings, artificial tear solutions in varying viscosities are prescribed. These range from eyedrops to high-viscosity long-acting gels that may be applied every hour or every half hour, depending on the severity of the disorder. In persistent cases, the puncta can be temporarily closed with silicone punctal plugs. Patients should also be informed about the possibility of installing an air humidifier in the home and redirecting blowers in automobiles to avoid further drying of the eyes. However, it is more often caused by obstructed drainage through the lower lacrimal system. O Increased irritation of the eyes (by smoke, dust, foreign bodies, injury, or intraocular inflammation) leads to excessive lacrimation in the context of the defensive triad of blepharospasm, photosensitivity, and epiphora. Causes of obstructed drainage: O Stricture or stenosis in the lower lacrimal system. Etiology: the disorder is often attributable to pneumococci and staphylococci, and less frequently to streptococci. There may be a relationship between the disorder and infectious diseases such as mumps, measles, scarlet fever, diphtheria, and influenza. Symptoms and diagnostic considerations: Acute dacryoadenitis usually occurs unilaterally. Clinical course and prognosis: Acute inflammation of the lacrimal gland is characterized by a rapid clinical course and spontaneous healing within eight Lang, Ophthalmology © 2000 Thieme All rights reserved. Diseases such as tuberculosis, sarcoidosis, leukemia, or lymphogranulomatosis can be causes of chronic dacryoadenitis. However, the S-curve deformity of the palpebral fissure resulting from swelling of the lacrimal gland is readily apparent (see. Prognosis: the prognosis for chronic dacryoadenitis is good when the underlying disorder can be identified. Lacrimal gland tumors are much rarer in children (approximately 2% of orbital tumors). The relation of benign to malignant tumors of the lacrimal gland specified in the literature is 10: 1.