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Practical Psychology in Medical Rehabilitation

The medical record is the central source for information in the inpatient and acute medical setting. While the organization of the medical record may differ slightly depending on setting, medical documentation is universal in medical care and provides the essential vehicle for communicating and documenting information across multiple disciplines. In the acute and subacute medical setting, the medical record is a dynamic and “living” document with contributions from those providing direct clinical care and treatment, documentation of results, as well as information to determine future intervention and discharge. The following chapter provides basic information on record organization, data-gathering strategies, and typical types of clinical documentation used in medical rehabilitation . It is important for psychologists to be familiar with the medical record and interview components as well as effective documentation to ensure efficient data gathering and to provide salient information to aid in patient care.

Psychiatry and the Law

As a student, trainee, or mental health practitioner, one may already have some inclination that understanding the law matters in the practice of psychiatry. But what is it exactly that makes the law so important? And why in psychiatry in particular ?State and federal laws have a signifcant impact on the practice of medicine. The practice of psychiatry is particularly affected as it is the most heavily legally regulated of all medical specialties . The reason is relatively simple: far more than any other medical discipline, the law grants psychiatrists the ability to deprive people of their civil liberties. Psychiatrists may force interventions on patients against their will—including hospitalization, medication, or even electroconvulsive therapy (ECT). Further, in a variety of settings, psychiatrists are tasked with determining whether patients lack the capacity to make certain decisions for themselves —including decisions related to medical care, fnances, and estate planning—and are in need of surrogate decision-makers. In some states, any physician may enact such privileges; however, in practice, psychiatrists are most often called upon to make these determinations . Thus, the privilege to override individuals’ rights to autonomy is subject to careful legal oversight and protections. So how does the law impact the practice of psychiatry? State and federal laws delineate the limited circumstances within which psychiatrists may deprive patients of their civil liberties. Patient autonomy is generally protected except in cases involving serious concerns about safety or well- being.

Management of Anemia

While kidney disease can be a result of many different etiologies, its functional marker is a rise in serum creatinine, a decline in estimated glomerular fltration rate (eGFR), or a change in urine to include proteinuria or proteinuria plus hematuria. Because serum creatinine is not linearly related to kidney function given that it is confounded by the amount of muscle mass of the person in which it is measured, itis necessary to estimate kidney function using one of three formulae that convert serum creatinine to estimated glomerular fltration rate (eGFR) or creatinine clearance (CrCl). The MDRD and CKD-EPI formulae are both used to calculate eGFR
, while the Cockcroft-Gault formula can be used to calculate CrCl (Table 1.1). Both measures (eGFR and CrCl) are provided in units of milliliters per minute and measure how much blood is “cleaned” or “processed” by the kidney per minute. While there is no defned “normal” for eGFR and CrCl, key points to remember are that any values around 100 mL/min are likely not to represent a decline in kidney function. As eGFR and CrCl decline, an individual has less kidney function and more advanced levels of kidney disease and can be used to describe the stage of kidney disease for the individual (Table 1.2) .

Failed Anti-Reflux Therapy

Initial and scarce attempts to operate the esophagus have been described since the seventeenth century, mostly due to traumatic injury ; however, the real history of esophageal surgery is relatively young compared to other organs. According to Fogelman and Reinmiller , esophageal surgery was both uncommon and poorly performed prior to the nineteenth century. This may be attributed to the fact that the esophagus is a peculiar organ. It has a unique anatomy: (1) important organs surround the esophagus in its entire length; (2) the esophagus crosses the neck, the chest, and the abdomen; (3) it lacks a serosa and its own artery, and (4) the lymphatic drainage is abundant and erratic . This leads to an exclusive surgical anatomy: (1) access routes to the esophagus may be variable and multiple; (2) oncologic margins are elusive; and (3) organs need to be prepared in order to replace it . Also, the esophagus has a distinctive physiology: (1) it is a digestive organ without known absorptive or endocrine functions; (2) it is bounded by two sphincters; and (3) it exhibits a motility pattern only at feed and different from other digestive segments.

Underactive Bladder

Underactive bladder (UAB) and detrusor underactivity (DUA) are common, aging-related, multifactorial conditions• Aging may be an etiological factor, but concomitant disorders may aggravate aging-induced reduction in bladder structure and function • Bladder outflow obstruction, diabetes mellitus, neurogenic disorders, and ischemic bladder dysfunction, are often associated with UAB/DUA• Impaired detrusor contractility has been regarded as a major etiologic factor of UAB/DUA, but disturbances of bladder sensory afferents and the central nervous system control of micturition and changes in efferent neurotransmission may be as important • Chronic bladder ischemia and resultant oxidative stress may cause detrusor overactivity progressing to DUA and inability to empty the bladder.

Whole Person Care

When my wife and I were in our early 20s, she developed sarcoidosis. It was the acute kind with hilar lymph nodes and erythema nodosum. That seemed to be the diagnosis, but I was a medical resident and as much as I wanted to believe this was an acute episode that would resolve, she and I both feared this might not be so. To me those lymph nodes on her chest X-ray looked very threatening. Could this be a lymphoma? And if it was sarcoidosis, how would it resolve? Were we facing a chronic illness ?I was not a stranger to the diagnosis of sarcoidosis. I myself had been diagnosed with possible sarcoidosis when I was 14. I remember that time very vividly: opening an envelope that I was to give to a radiologist and seeing the word sarcoidosis with a question mark and going to the library to fnd out that this disease could involve many organs—the lungs, the joints, the skin, and the heart. The 5-year mortality was quoted at 5–10%. It was terrifying. But what I remember best was leaving the doctor’s offce on a rainy dull Irish winter day with a prescription for pills. I looked at people passing me by and thought “They are normal” and “I have joined the ranks of the sick.” I had a dull feeling in my abdomen, my life was over.

Teaching Medicine and Medical Ethics Using Popular Culture

There is an increasing awareness of the role of mass media and popular culture in communicating health information to the general public and medical students.1 Medical television series in particular have been identifed as a rich source of health information and medical ethics training, depicting doctor–patient relationships that are both entertaining and educational. Recent research has shown that these fctional representations of the medical profession have an impact on perceptions of real-life doctors, and can infuence recruitment of students into medical, nursing and health science degrees.2 Beginning with CBS’s City Hospital in 1951, medical television dramas have remained a staple of prime-time television.3 In his book, Medicinema, Brian Glasser notes that popular flm culture and medicine have always been intricately connected, with flm historians placing the frst representations of medical personnel in fctional flms before that of ‘cowboys, criminals or the clergy.’4 With such a historically entrenched relationship between fact and fction, it is unsurprising that medical dramas regularly come under scrutiny regarding their potential infuence on public perceptions of doctors and the health system.5 Furthermore, there is ongoing debate regarding the usefulness of televised medicine in medical and health science curriculum, with Roslyn Weaver and Ian Wilson reporting that university educators often seem concerned about ‘how the fctional world of medicine intrudes on and infuences the real one.

Severe Asthma

Bronchial asthma is now widely recognized as a heterogeneous clinical syndrome consisting of various disease phenotypes. Each asthma phenotype may have distinct observable molecular, cellular, morphological, functional, and clinical features , all of which can be possibly integrated into specifc biological mechanisms, called as endotypes . Although differentiating asthma into various phenotypes/endotypes remains speculative so far, these concepts of separation may be useful in characterizing and predicting disease severity, progression, and response to general and specifc therapies including biologic medications . This is particularly important for severe asthma patients who are refractory to current standard therapies including inhaled and systemic corticosteroids (CS) and bronchodilators. Because these patients account for a signifcant proportion of health-care expenditure of asthma , recognizing the heterogeneous nature of asthma, especially severe asthma, may enable us to develop safe and effective phenotype-targeted biological therapies.

Medical Problems During Pregnancy

P.A. is a 27-year-old healthy primigravida who is currently 24 weeks pregnant with a single fetus. She has a history of gastroesophageal reflux disease (GERD) diagnosed several years ago. At that time she took daily omeprazole for symptoms that occurred approximately 3–5 times per week, 1–2 times per day. Her BMI was 26 (ideal BMI 18.5–24.9), and weight loss was recommended. Over the course of a year, she managed to lose weight with diet and exercise. Her symptoms improved, nd, ultimately, she was able to discontinue omeprazole without diffculty. She never underwent endoscopic evaluation, as her symptoms were uncomplicated and resolved with proton pump inhibitor (PPI) therapy. Her mother is overweight with hypertension and her maternal grandfather has diabetes. She has one younger sibling whose only medical issue consists of seasonal allergies. She has no family history of gastrointestinal malignancies. She is a nonsmoker and denies current alcohol consumption.

Male Breast Cancer

There is substantial evidence of deleterious health behaviour in males both in terms of high-risk activities and avoidance of contact with doctors. This manifests as delay in diagnosis and upstaging of disease with a consequent worsening of prognosis. The incidence of male breast cancer is rising worldwide and this is not just as a result of increasing lifespan in that age standardised rates are also increasing. Neonatal breast tissue demonstrates plasticity irrespective of gender. Normal male breast anatomy is similar to that of prepubertal females but is often overshadowed by the presence of gynaecomastia, particularly in the overweight. The lack of model systems including established human MBC cell lines has hindered research but with collaborative studies there is promise of better understanding and treatment for MBC in the future.

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