Doctor-patient relationship: The nature of Doctor- Firstly buy 160mg kamagra super mastercard erectile dysfunction newsletter, conception can take place during any period; patient relationship is a debatable topic quality kamagra super 160 mg erectile dysfunction treatment hyderabad. Thus discount 160 mg kamagra super with amex erectile dysfunction aids, in human at it from the physician’s point of view, it seems to be beings, there is a controlled fertilization. This is also a secondary relationship because: in favor of living together in a planned manner. Cultural development: The above five elements • It starts from a particular date and it ends after the can be identified in many animals in varying degree. It can be simply understood as “An art of point of view of the patient’s psychology, the following adding experience”. There is a contract The basis of group is Emotion Underlying basis is business Relation is first. Relation is secondary It is “face to face” or related with “we” feeling No such feeling The relation is present even if the group is not physically there No relation or group feeling after the contract is over The relation is not transferable. Any person can come and replace the else the first one as in business deals There is a unique sense of satisfaction attached with the There are no emotions and no such feelings are present particular person Example: Family, friends Example: Business deals, classmates, etc. Various social norms and their origins are on occurring frequently and, by and large, patients explained in Figure 12. Most Various types of norms, can be considered according people have their family doctors, the relation with to– Range of acceptance and Range of enforceability. Without an element penalised but because it is obligatory in the proper of emotion on the part of the doctor and without situation. They are enforced by informal social controls an element of faith on the part of the patient, the like gossip and ridicule. Examples of such expected forms of • The relation is not transferable from the patient’s behavior include the ways of greeting, dressing, eating, point of view. Folkways vary from society to society and culture the same doctor on a follow-up visit even in a to culture. They are available, a patient would prefer to visit again and necessary for the group solidarity. Vitality of a group is see his earlier doctor rather than be seen by a new indicated by the extent to which people follow or abide doctor on each visit. There is greater feeling We have already said that society is an organization of horror about violating mores and greater unwilling- made by man for himself. Every living organism has some basic requirements and tries its best to satisfy them. In animals, these needs give rise to the basic desires or instincts which the animal tries to satisfy without inhibition. In man, the biological forces trigger the desires but, contrary to animals, there are social standards which guide man. The resultant of these two forces is the actual behavior, which we perform in society. Whenever he feels hungry, he starts crying and keeps on crying till his desire is fulfilled. As the child grows, he can tole or can be made to understand that “please wait, food is not ready” and the child can resist his hunger. The day to day teaching and learning constitutes an important functional aspect of society. Social Norm s 128 Every society specifies certain rules of conduct to be followed by its members in certain situations. While each folkway is not Etiquettes and Conventions considered tremendously important and is not Etiquettes are concerned with choice of the proper form supported by an extremely strong sanction, each more for doing something in relation to other people. Thus are informal and the reactions of the group are entering a bus from the rear with exit from front is a spontaneous rather than official action. When a procedure is adopted and repeated transformation of informal expectation (Folkways) to time and again, it may become a rule. Examples are abstinence from beef, pork and smoking in Hindus, Muslims and Sikhs respectively and Like social norms, values also constitute an important from marrying outside one’s own ethnic, caste or part of the selective behavior of man. It is said that norms are not only prescribed in written form but are enforced are the enactment of social values. Every society lays through specific machinery created by society for this down certain rules of conduct to support its value purpose. Norms are repeated, sanctioned pattern of We can illustrate the concept of folkways, mores and behavior and their philosophical facet is the value. The institution example, it is a norm that no man should be of marriage involves several obligations such as: differentiated in terms of sex, caste, color or creed while • Barat or the marriage party practising the art of medicine. The value behind it is that • Performance of garlanding ceremony “all men are born free and equal. These obligatory ways are all expected to be per- Anthropology is the study of man and his works. Physical anthropology is the study relating to the number of persons in the marriage party, of man as a biological organism. On the other Its major theme is culture, which is defined as the hand, it is never expected that a boy may come alone accumulation of learned behaviors, beliefs, skills, etc. Some witnesses, at least, must be cultural anthropology are ethnology and archeology. Without Linguistics is sometimes regarded as a third branch of these, marriage may be a nullity in law. Ethnology is the comparative feels that its vital or organic essense is in danger due to study of cultures. Archeology is the study of past cultures violation of some conduct or mores, these are written and civilizations and uses their remains as the principal and codified, e. Social anthropology is a specific branch of cultural Custom s and Habits anthropology dealing with comparative study of kinship Custom is a broad term embracing all the norms and nonkinship organization patterns in different classified as folkways and mores. The other hand, a Habit is a purely personal affair, not Oxford English dictionary defines culture as, “the entailing any obligation. Examples are having a cup of training and refinement of mind, tastes and manners, bed tea, smoking a cigarette after dinner, eating two the condition of being thus trained and refined”. When habits are shared is distinguished from animals by virtue of the fact that 129 for their necessity and are sanctioned by the society, they he possesses a culture, i. He is humanist, has sympathy towards others and understands his fellow shelter decreases the defence mechanisms of the beings. Ways • Communicable disease are related to low of life are cultivated or cultured in an individual by standard of living in a community. It is an experience which is childhood delinquency, sexually deviant behavior “learned, shared and transmitted”.
The ground rule was that no one would Within the context of a day treatment neuropsychological discuss the psychological significance of a person produc- rehabilitation program (Prigatano 1986) purchase 160 mg kamagra super with visa best herbal erectile dysfunction pills, individual and ing a certain song cheap kamagra super 160 mg visa treatment of erectile dysfunction using platelet-rich plasma, but rather group members would dis- group psychotherapy sessions would begin with the psy- cuss the feelings that were generated in them by listening chotherapist asking the patient or patients what they to the song that someone else picked order kamagra super once a day erectile dysfunction self injection. This was not a “tech- wished to discuss during that session, in light of what was nique” of psychotherapy. Many times, the review of previous entering each other’s phenomenological field in a non- material did lead into a continuation of a previous discus- threatening way. The patient might be- helpful, and if introduced at the proper time can reduce come tangential or confused over what the next topic social isolation and help patients begin to discuss impor- would be. During these times, the psychotherapist would tant emotions that are stimulated by the lyrics and the tone take the lead in clarifying what was said, at times moving of various songs. The have written poems (Prigatano 1986), done drawings and failure of the patient to reconstruct in a clear way what was paintings (Prigatano 1986, 1999), and told stories (Priga- previously said, even with the presence of notes, does not tano 1991) that reflect their culture, their personal back- necessarily represent resistance to the psychotherapeutic ground, and what they experience “right now” as it relates process. It frequently reflects the problems that patients to the impact of their brain disorder on their life. These art have in abstract thinking, memory, and initiating a logical forms have been helpful in conveying what the patient ex- discussion. Patients were told that if it was difficult for periences and often provide a connection with the treating them to bring up a topic on any given day, the psychother- psychotherapist. Again, the use of these art forms is not apist would attempt to lead the discussion. It is the responsibility of the psychotherapist to help pa- Goldstein (1952) noted that many patients with brain tients use appropriate compensations to review and discuss dysfunction try to reduce disorder in their life and thereby the content of therapy sessions. Taking these steps may cir- avoid the catastrophic condition (Pollack 2005 discusses cumvent many of the problems caused by brain injury that this point in some detail). These art forms use symbols to can negatively impact the psychotherapeutic process and maintain order and meaning to the patient’s life. These are Finding Areas of Mutual the symbols of work, love, and play (Prigatano 1989, 1999). Psy- symptoms of anxiety, depression, and interpersonal con- chotherapy initiates the process of talking about (and ex- flict between people. It is geared to helping people have an periencing) thoughts and feelings that influence a patient’s acceptable sense of self, meaning that they feel comfort- behavior and sense of well-being in life after brain injury. Their purpose and ably well and how he or she functioned before the brain direction are unclear. They have lost the acceptable sense injury to conduct meaningful psychotherapy with the pa- of self (Luria 1972; Pollack 2005). It is for this reason that the pa- als to reconstruct their lives, psychotherapy can assist tient’s history, as told by the patient, must guide the psy- them in relating to the symbols of work, love, and play, chotherapeutic process. These symbols are important in Western culture be- Taking Time to Listen to cause a person’s ability to work suggests that the person is able to be productive and potentially self-sustaining. It also provides an im- In his memoirs, Carl Jung (1965) had the following to say: portant social contact in that work puts a person in touch with other people and often is a way of shared meaning Clinical diagnoses are important since they give the doctor with others. The The ability to love is, of course, the most important sym- crucial thing is the story. It translates into background and the human suffering, and only at that our capacity to be empathetic to others’ needs and situa- point can the doctor’s therapy begin to operate. It allows us to show joy and pleasure Every human being has an important story to tell about his in others’ accomplishments and sense of personal well- or her life. When we are able to work and to love, we are able to reflect how the person responded to unexpected events in begin to function again in a normal fashion. These However, people who work and love may still have a experiences often are crucial in how the person subse- sense of depression or emptiness about life. They can become de- any significant loss, a person often reflects on those stories pressed and angry. Yehuda Ben-Yishay years ago made and what they have told the person about life and how to the comment: “You cannot be a sourpuss and be rehabili- deal with life in an adaptive fashion. What he meant by values, and relationships are held in question when they this is that you have to get past the anger and the depression no longer guide the individual in dealing with present life in order to be meaningfully rehabilitated. Jung was especially aware of this and tried capacity to relate to symbols that help you become the in- to have individuals deal with their life’s problems in light dividual that you are within the context of a given culture of their cultural and religious backgrounds. The symbol of play highlights this psychological When a person seeks help with the effects of brain injury, goal (see Prigatano 1999 for further discussion of this point). As Pollack (2005) noted, “suc- ness of neuropsychological rehabilitation (which include cessful psychotherapeutic work with people who have expe- psychotherapeutic interventions) must find objective and rienced a brain injury usually requires that the therapist use subjective markers of whether these important goals have several different approaches to treatment” (p. While the severity, location, and type of brain of lost normality (Prigatano 1999). This requires a knowl- injury will produce predictable neuropsychological and edge of the patient’s neuropsychological deficits, which may psychiatric disturbances (see Prigatano 1999; Prigatano include a disturbance in self-awareness. The psychothera- and Maier 2009), these disturbances are always interacting pist must also have an informed understanding of the reali- with the premorbid characteristics of the patient (Priga- ties of a given patient’s life. Therefore, one must know the patient reason- become independent with rehabilitation? Can the patient be 574 Textbook of Traumatic Brain Injury gainfully employed, and if so, in what work capacity? What Psychotherapists must understand that human con- types of emotional changes are necessary for the patient to sciousness evolves to guide brain function and to expand accept a lower salary or less job responsibilities? How this context, human beings search for meaning in life to can the therapist help the patient see these realities and ad- deal with suffering and losses. Those approaches do not focus Finally, the psychotherapist has to face the fact that not on the patient’s shattered sense of self, loneliness, and loss all behavior is consciously motivated. There seem to be un- of meaning in life, nor do they adequately consider the his- conscious motivations that influence what people do and torical influences and the patient’s subjective experience. Many behaviorists may disagree with Understanding these issues is necessary to reducing the such a statement, citing a lack of evidence. Understanding these “basic facts” about human suggestions are reproduced, with permission, in Table 36–1. Although the table will not be re- viewed in its entirety in this section, many of the points made by Pollack are discussed elsewhere in this chapter. Special Problems Associated The reader is encouraged to review this table periodically as a helpful reminder of things to attend to in the process With Brain Injuries of doing psychotherapy with brain-dysfunctional patients. The phenomena of transference and countertransference are extremely relevant and have to With Which Psychotherapists be carefully managed. The catastrophic reaction associated with various brain disorders is often not properly under- Must Be Familiar stood, and yet can have a great impact on the patient’s over- all adjustment (Goldstein 1952). Neuropsychological reha- Behavior is a function of its consequences or lack thereof bilitation must begin with an effort to understand this (Skinner 1938).
If a pregnant patient presents with a frst seizure buy kamagra super 160 mg free shipping impotence lab tests, it Br J Obstet Gynaecol 1996; 103: 123–29 cheap 160mg kamagra super free shipping causes of erectile dysfunction in late 30s. However purchase 160mg kamagra super otc erectile dysfunction vascular causes, if the clinical features are not con- Does gestational hypertension become sistent with a pre-eclamptic pathology (that is, there pre-eclampsia? Br J Obstet Gynaecol 1998; is no hypertension, proteinuria, or additional bio- 105: 1177–84. Electrolyte abnormalities and Prediction of 24-hour protein excretion hypoglycaemia are easily diagnosed with initial bio- in pregnancy with a single voided urine chemical screen. Am J Obstet occur in pregnancy, as this diagnosis is ofen made Gynecol 2002; 186: 883–86. Use frst seizure clinic under the care of neurologists is of a random urinary protein-to-creatinine appropriate where additional investigations such ratio for the diagnosis of signifcant protein- as electro-encephalograms can be performed and uria during pregnancy. Am J Obstet carried out to exclude space-occupying lesions such Gynecol 2000; 183: S1–S22. Accuracy of plained seizure owing to the innate pro-thrombotic serum uric acid in predicting complica- state of pregnancy. The Eclampsia Trial Collaborative Group heparin and referral to haematology for investigation (1995) Which anticonvulsant for women of any additional thrombophilias. The 8th and management of small for gestational report of the confdential enquiries into age fetus. Arthritis depending on the frequency of incontinent episodes Rheum 1982; 25: 1271–77. However, the efect on the quality of life will also depend on the type (fully formed stool, liquid stool, or fatus) and volume of stool lost. Visvanathan Damage may occur during childbirth in three ways: Faecal incontinence may be defned as ‘any involun- tary loss of faeces or fatus, or urge incontinence that adversely afects the quality of life’. The prevalence of faecal incontinence on ruption can occur in with a clinically obvious third- direct questioning of women before pregnancy, at 34 or fourth-degree perineal laceration, or as an occult weeks’ gestation, and afer delivery was found to be injury subsequently noted on ultrasound scan of the 0. Incontinence may be passive (where the woman Injured nerves ofen undergo demyelination but in unaware), urge (where it occurs despite active usually recover with time. The most signifcant Iatrogenic factors that cause sphincter damage include forceps Obstetric delivery and a previous sphincter injury. A ran- Fractures of the pelvis domised control trial found clinical third-degree Impalement tears in 16 per cent of women with forceps-assisted Denervation deliveries, compared with 7 per cent of vacuum- Obstetric assisted deliveries. In these studies, the Cerebral type of incontinence is mainly of fatus (30 per cent) ● Multiple stroke and leakage of liquid stool (8 per cent), while leakage ● Metastases and other tumours of solid stool occurred in 4 per cent. If symptomatic, they should be ofered endoanal sphincter damage at childbirth ultrasonography with anorectal manometry and referral to a colorectal surgeon for consideration of Primary prevention secondary sphincter repair. Spontaneous over instrumental vaginal delivery Vacuum extraction over forceps delivery Restrictive use of episiotomy Management in a subsequent pregnancy Mediolateral episiotomy over medial episiotomy Antepartum pelvic foor exercises and antepartum Subsequent vaginal deliveries may worsen anal perineal massage incontinence symptoms. Tese women are also at Consider caesarean section increased risk of repeat injury to the anal sphinc- ter complex. All women who have had a third- and secondary prevention fourth-degree tear in their previous pregnancy Early detection and proper repair of perineal injury should be counselled regarding the risk of devel- tertiary prevention oping anal incontinence or worsening symp- Consider lower segment caesarean section for toms with subsequent vaginal delivery. If they are women with childbirth injuries to the pelvic foor symptomatic or with abnormal endoanal ultra- in future pregnancies sonography or manometry, the option of elective caesarean section should be discussed. Management of third- Immediate repair and fourth-degree perineal tears follow- It is standard practice to repair a damaged anal ing vaginal delivery. Antenatal prediction of postpar- rectum to assess the severity of damage prior to tum urinary and fecal incontinence. Mt Sinai J Med 2000; end-to-end approximation of the cut ends; overlapping the cut ends and suturing through the over- 67: 96–105. Anal sphincter ‘functional or damage after vaginal delivery: functional situational’ outcome and risk factors for fecal inconti- Overactive + Normal = Urge urinary nence. Repair leakage of urine, whereas leakage tends to be episodic of obstetric perineal lacerations. Effect of sec- confusion, dementia, diabetes mellitus or insipidus, ond vaginal delivery on anorectal physiology and cardiac failure, as well as some drugs, in par- and faecal continence: a prospective study. The dence increases with age, so prevalence in the elderly 2 second aim is to identify any treatable causes of the is around 50 per cent. Voiding diaries divided into bladder and/or outlet dysfunction (see should be completed for at least 3 days and urinal- Table 1). A measurement of post-void residual uri- congenital – ectopic ureter, spina bifda occulta; nary volume is useful. A cystometrogram should be acquired – fstula, which can be due to tumour, infection considered if the type of incontinence is not clearly and childbirth, or be iatrogenic (surgical). Tis is desirable, if any surgical intervention Physiological causes include: is planned, as the exact form of incontinence has to bladder dysfunction; be clearly defned preoperatively because inappropri- urethral/outlet dysfunction; ate surgery on a unstable bladder may aggravate the a mixture of both of the above. Tis clas- incontinence sifcation system is based on whether the detrusor muscle in the wall of the bladder is functionally over- treat any underlying cause active (sometimes termed ‘unstable’ or ‘irritative’) Infection, infammation, obstruction, calculus, or refexive (underactive), and depends on whether neoplasm, neurological disease, etc. The main symptom is the loss of urine Botulinum injections with the feeling of urgency, voiding before the ability Sacral nerve stimulation to get to the toilet. It can be a difcult problem to Augmentation cystoplasty treat, with varying levels of success. The main Biofeedback symptom is the involuntary loss of urine with activity Pelvic foor exercises (Kegel) for at least 3 months’ (coughing, laughing, sneezing, lifing, or straining). Descriptive epidemiology of defciency urinary incontinence in 3,100 women age 30–59. Tension-free transvaginal/obturator mid-urethral Long-term Care and Facility Improvement tape procedures Study. Intercourse should occur Endometriosis 2–3 times in the week prior to ovulation: though the Antibodies to sperm oocyte (egg) will be capable of fertilisation for only Age 24 hours, the sperm will retain potency for up to Male factors 72 hours. Intercourse prior to the day of ovulation Sperm-production problems also encourages remodelling of the endometrial lin- Azoospermia (no sperm in the ejaculate) ing, making implantation more likely. Secondary infertility is when the couple has had at least one pregnancy together, irrespective of the Lifestyle factors outcome. The man has a known or suspected reproductive tract pathology, such as an undescended testis. The couple present because they have not conceived as quickly as they had expected. The egg and sperm need to be able to get together A couple are in their 30s, as increased age affects their (there is no tubal disease, sperm antibodies, or sexual chance of conceiving. Some of the distress associated with fertility The couple have avoided lifestyle factors that may affect problems can be reduced by prompt investigation egg and/or sperm quality. It is important to emphasise for more than one pathology to be afecting their that establishing a diagnosis or cause of the infer- likelihood of conceiving. For a couple to conceive normally, the following are required: Female factors If a couple presents for fertility investigations, the The woman needs to produce and release a mature, healthy egg (oocyte) on a regular basis (ovulation). However, from amenorrhoea (see Menstrual periods, absent) the prolactin levels should be repeated initially to through oligomenorrhoea (see Menstrual periods, confrm the raised concentration, as stress alone can infrequent) to irregular cycles. A serum progesterone level history of anovulation for some months, particu- of >30 nmol/L is consistent with a normal ovulatory larly if there is a family history of early or premature cycle.
By E. Dargoth. Bowdoin College.