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RECORD KEEPING 67 Always note any expression of non-compliance regarding discharge in­ structions purchase geriforte syrup 100caps without prescription, and your actions in response to this generic geriforte syrup 100 caps overnight delivery. Much of the above information can be summarised in a discharge re­ port buy geriforte syrup 100 caps without prescription. Key documents to be kept on file: q results of assessments and investigations relating to the discharge decision q copies of referrals to other services q copy of discharge instruction sheets given to clients including directions about medication cheap 100 caps geriforte syrup overnight delivery, self-administered health care or therapy regimes q discharge reports purchase geriforte syrup 100 caps without prescription. Post-discharge The health records of clients who have been discharged must be retained for the recommended period of time. This will include carrying out ad­ ministrative procedures to record that the notes are in discharge, thereby ensuring easy access to them in the future. Work with a colleague and audit a sample of each other’s clinical notes. Are there any areas where you are consistent in not meeting the standards? Notes 1 Options that involve clients actively in record keeping are likely to increase their motivation and understanding of the care process. A c t i o n s R e c o r d K e e p o n f i l e R e f e r r a l / f i r s t * S e t u p p e r s o n a l h e a l t h * C l i e n t i d e n t i f i c a t i o n d e t a i l s * R e f e r r a l f o r m o r l e t t e r / a d m i s s i o n s l i p c o n t a c t r e c o r d * R e a s o n f o r a n d d a t e o f r e f e r r a l o r a t t e n d a n c e * A c c o m p a n y i n g r e p o r t s * N a m e a n d p o s i t i o n o f t h e r e f e r r e r I n i t i a l * E v a l u a t e c l i n i c a l n e e d * A c a s e h i s t o r y * C a s e h i s t o r y f o r m o r a d m i s s i o n s h e e t a s s e s s m e n t * C l i e n t ’ s v i e w s a b o u t t h e p r o b l e m * C l i n i c a l o b s e r v a t i o n s * T e s t s , i n v e s t i g a t i o n s a n d p r o c e d u r e s * C o n s e n t f o r m s f o r s p e c i f i c * I n t e r p r e t a t i o n i n v e s t i g a t i o n s * D i a g n o s i s / p r o g n o s i s * F o r m s o r c h a r t s u s e d i n t e s t s , i n v e s t i g a t i o n s o r p r o c e d u r e s * A c t i o n s / r e c o m m e n d a t i o n s * C o m m u n i c a t i o n a b o u t * C l i e n t ’ s c o n c e r n s a n d v i e w s o n t h e a s s e s s m e n t * A c o p y o f r e p o r t s o r l e t t e r s c i r c u l a t e d a s s e s s m e n t a n d o u t c o m e a b o u t t h e a s s e s s m e n t * R e f e r o n a s a p p r o p r i a t e * C o p i e s o f r e f e r r a l l e t t e r s t o o t h e r p r o f e s s i o n a l s I n t e r v e n t i o n * S e t c a r e p l a n * R e c o r d o b j e c t i v e s * C o n s e n t f o r m s f o r t r e a t m e n t , t h e r a p y * R e c o r d c l i e n t ’ s v i e w s a b o u t c a r e p l a n o r s u r g e r y * C a r e p l a n F i g u r e 4. This chapter reviews how to plan, structure and present such correspondence. The two are distin­ guished from each other by different styles, presentation and tone. Formal letters refer to correspondence that has an official or business function. They are printed or typed on headed paper using a conventional style of composition. The manner of address is formal rather than personal, so the preferred title and last name of the recipient is used to start the letter. They are signed off with the name, position, title and qualifications of the letter writer. Informal letters are written using a more conversational tone and are sent between two people who know each other. Letters are only one of the means of communication available to the health professional; however, they have certain advantages over other methods. Choose a letter if you want to: ° present complex information and elaborate on ideas ° have time to organise your thoughts and review your intended message ° have a confidential means to convey information 71 72 WRITING SKILLS IN PRACTICE ° indicate to the recipient the seriousness of the matter under discussion. Sometimes a letter is not always the most appropriate or most sensitive choice of communication. If your message: Consider using: is urgent e-mail, fax, telephone is an apology telephone, face-to-face contact requires explanation face-to-face contact, telephone is informal, brief or a reminder e-mail, memo requires discussion or exchange meeting, of ideas or involves decision making video or telephone conferencing. Structure of letters Letters consist of: ° a greeting ° an introduction ° the main body ° the conclusion ° a closing sentence ° a signature. Greetings The way in which you address the recipient will depend on whether you are writing a formal or informal letter. In certain circumstances a more gen­ eral term like ‘client’ or ‘parent’ may be permissible in letters sent en masse or if you are unable to verify the recipient’s name. Introduction The first paragraph will state clearly the reason or purpose for writing. LETTERS AND REPORTS 73 The following examples show how the use of some pertinent details (including the date) helps the writer indicate the topic or subject of the message to the reader. In response to a letter or other type of contact – ‘Thank you for your letter dated … regarding …’ or ‘Thank you for your phone call on the … I am sorry I was not available to speak to you personally’; ‘I am writing to you regarding your enquiry on the … about the waiting list for day sur­ gery. I would like to find out whether it would be possible to install a barrier that will restrict access to staff mem­ bers. For example, referral let­ ters usually start with a sentence like: ‘Thank you for seeing this elderly gen­ tleman who has been complaining of chest pains for the last three days. Conclusion The content of the conclusion will vary according to the purpose of the letter.

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Cells can be independent organisms buy generic geriforte syrup 100 caps online, as in a bacterium buy 100caps geriforte syrup mastercard, or order 100 caps geriforte syrup amex, by co-operating with other cells cheap geriforte syrup 100caps with mastercard, form tissues discount geriforte syrup 100caps with mastercard. By acquiring specialised functions, assemblies of tissues form the next distinct structural and functional unit, the organ. At the highest level, a human comprises 75 000 000 000 000 cells divided into ten major organ systems. It is natural to describe the function at each level in the biological hierarcy in terms of the components at the next level down. Sometimes it is necessary to consider processes occurring two levels down, but further subdivision is seldom beneficial. Schrödinger’s equation, for example, is useful when modelling the behaviour of atoms in a molecule, but it would be absurd to model car crashworthiness using this level of detail. When we are interested in the operation of a complete organ, a description at the level of the cell is the natural choice. The model must incorporate both the operation of the cell in isolation and the interactions between cells since, by analogy, we could not predict the load-bearing capacity of the Forth Rail Bridge by considering only the strength of the individual cantilevers in isolation. The structural properties of bone are determined by non- cellular organic and inorganic components. The potential exists to assess quantita- tively an individual patient’s risk of bone fracture, which has significant clinical implications in an ageing population. Currently, estimates of this risk are limited by the inability to allow for complex structural features within the bone. However, if the internal structure of a bone was determined in vivo, using X-ray-based computed tomography, an accurate finite-element model could be built to estimate the maximum load that can be borne before fracture. Finite-element models can aid in surgical spine-stabilisation proce- dures, thanks to their ability to cope well with the irregular geometry and composite nature of the vertebrae and intervertebral discs. The acellular structure of real bone is modified continuously accord- ing to the internal stresses caused by applied loads. This process, which represents an attempt to optimize the strength-to-weight ratio in a biolog- ical structure, is achieved by the interaction between two types of cell, one that absorbs bone and the other that synthesises new bone. New bone is added where internal stresses are high, and bone is removed where stresses are low. An accurate finite-element model of this combined process could be used clinically to determine the course of traction that will maximise bone strength after recovery from a fracture. Another well-established area of mechanical finite-element analysis is in the motion of the structures of the human middle ear (Figure 9. Of particular interest are comparisons between the vibration pattern of the eardrum, and the mode of vibration of the middle-ear bones under normal and diseased conditions. Serious middle-ear infections and blows to the head can cause partial or complete detachment of the bones, and can restrict their motion. Draining of the middle ear, to remove these products, is usually achieved by cutting a hole in the eardrum. Finite-element models of the dynamic motion of the eardrum can help in the determination of the best ways of achieving drainage without affecting significantly the motion of the eardrum. Finite-element models can also be used to optimise prostheses when replacement of the middle-ear bones is necessary. The outer ear collects sound and directs it down the ear canal towards the eardrum. The size of the eardrum, combined with the lever action of the three bones of the middle ear, ensures the efficient conduction of sound from the ear canal, which is filled with air, to the inner ear, which is filled with a liquid. Very small muscles, not shown here, are connected to these bones to protect the ear from very loud sounds. Only the cochlea is shown, which is the part of the human ear that is responsible for converting sound into electrical signals in the auditory nerve. The other part of the inner ear, the vestibular organ, is involved in balance. Finite-element techniques can cope with large, highly non-linear def- ormations, making it possible to model soft tissues such as skin.

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Most spine surgeons recommend preventive stabilization surgery in Duchenne dystrophy once the patient is nonambulatory and clearly progressive curvature exceeds 20 degrees order 100caps geriforte syrup with visa. Other surgical approaches generic geriforte syrup 100caps with mastercard, such as more limited spinal surgery with lumbar fixation at L5 discount geriforte syrup 100 caps mastercard, are also undergoing evaluation buy 100caps geriforte syrup amex. Prior to spinal stabilization surgery and prior to any major surgery in patients with Duchenne dystrophy 100caps geriforte syrup overnight delivery, it is necessary for the neurologist and primary care physician to obtain what will likely be ongoing consultative assistance from pulmonary medicine and cardiology. Treatment of Systematic Complications An involved pediatrician is critical in the early, middle, and late stages of Duchenne dystrophy. In the later stages, a mild cold may lead to atelectatic pneumonitis and acute respiratory insufficiency. Even chronic constipation can produce respiratory compromise in the later stages of Duchenne dystrophy due to abdominal distention and upward pres- sure on the diaphragm. Respiratory insufficiency is common in the late stages of Therapy for Muscular Dystrophies 213 Duchenne dystrophy. Recent reports describe the management options, which include nasal ventilation rather than positive pressure ventilation via tracheostomy. Considerable discussion is necessary to educate the patient and his family at this stage and to help to decide which options are most appropriate for them. Often neuromuscular physi- cians and nurses are the individuals who educate the family, and the roles of the pediatric pulmonologist and pediatrician have to be tailored to each medical care set- ting. The function of other organ systems may be compromised later in the course of Duchenne dystrophy, either as a direct consequence of the absence of dystrophin within vascular and gastrointestinal smooth muscle, within cardiac muscle, or as a downstream consequence of reduced skeletal muscle mass. Acute gastric dilation is one such infrequent complication in the late stages of Duchenne dystrophy. This typically occurs in association with an idiopathic metabolic acidosis and responds rapidly to nasogastric tube decompression of the stomach and intravenous hydra- tion. Caution must be used with intravenous repletion of potassium because in the late stages of the disease the muscle mass of the patient is considerably diminished and is not available to buffer an acute rise of extracellular potassium. Chronic intest- inal hypomotility (constipation) is also a recognized problem. Good hydration, a balanced dietary intake, and regular bowel habits are the mainstays of treatment for these problems. Occasionally, in the late stages of Duchenne dystrophy, patients develop symp- tomatic cardiomyopathy. Clinical expression of more common mild cardiomyopathy is masked by the diminished capacity for exercise due to skeletal muscle weakness. Symptomatic cardiomyopathy is associated with cardiomegaly with a reduced car- diac ejection fraction to 10–20% of normal. Heart failure often is exacerbated by coexisting respiratory insufficiency. In all these cases simultaneous ventilatory sup- port must be considered, provided the patient and his family have decided to pursue a vigorous course of treatment of his illness. Heart failure in its advanced stage is difficult to manage, and anticipaton of this complication by treatment with afterload reduction therapy often is more effective than later treatment with digoxin. Typi- cally, initial treatment is with an angiotensin converting enzyme inhibitor, titrating diastolic blood pressure to 60–70 mmHg. If left ventricular dysfunction persists or worsens, beta-blocker therapy is necessary with the goal of keeping heart rate between 55 and 70 beats per minute. Occasionally, ventricular and=or atrial clots are present, and long-term antic- oagulant therapy is necessary. Specific Treatments The only effective therapy for Duchenne dystrophy is prednisone. Double-blind, randomized, controlled studies have shown that prednisone in a daily dose of 0. These studies also have demonstrated that daily treatment is more effective than alternate-day therapy. Trials of deflazacort have shown efficacy equal to prednisone with fewer complications, but this agent is unavailable in the United States. How corticosteroids produce their beneficial effects in Duchenne dystrophy is unknown. The answer may lead to new, more effective, therapy with fewer side effects. However, there are several clues about the time course related to the benefit. Muscle mass increases 10% after 3 months of prednisone treatment, and by 6–8 weeks the rate of muscle breakdown declines in association with maintenance of a normal rate of muscle pro- tein synthesis.

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