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By M. Jerek. Irvine University College of Law.

Epidural analgesia was offered nearly twice as often to Jewish women as to the Bedouin (who preferred parenteral pethidine generic 5mg clarinex otc allergy symptoms early pregnancy sign, a synthetic opioid analgesic) cheap clarinex 5mg allergy forecast arlington tx. The most interesting finding came from the concurrent visual analog scores of the mothers and the care providers. The self-assessments of the Jewish and Bedouin women were nearly identical (8. These data are different from some of those reported earlier, in that they do not show undertreatment of an eth- nic group. Both groups of women had equal (albeit high) levels of pain at the time of assessment; what differed was the pain level judged by the de- livery staff from the exhibited behavior. It is uncertain whether this differ- ence was due to the behavior of the two groups, a bias on the part of the medical personnel, or their inability to recognize signs of pain in patients of a different culture. Pain Expression Diagnosis and treatment of pain are largely dependent on what the patient is willing to tell the health care provider or, for that matter, thinks is suffi- ciently important to report. The ethnocultural background of the practition- er is also likely to interact with that of the patient; a good physician or psy- chologist should examine his or her own attitudes and expectations about pain behavior. Davitz, Sameshima, and Davitz (1976), for example, asked over 500 nurses in the United States, Japan, Taiwan, Thailand, Korea, and Puerto Rico to read descriptions of patients and to judge their pain and psy- chological distress. The descriptions were brief and, in their own language, covered five disease categories, both sexes, three age levels, and two de- grees of severity. The study found that Japanese and Korean nurses be- lieved that their patients suffered a high degree of pain, while American and Puerto Rican nurses rated their patients’ pain fairly low. ETHNOCULTURAL VARIATIONS IN PAIN 163 counter to the stereotype of Asian stoicism. Consequently, Asian patients treated in North American hospitals might receive less treat- ment than their pain level would warrant. Interestingly, other stereotypes, which could be quite dangerous to the patient, were shared by the nurses in all six cultures. For one, males were seen as in less pain than females for similar degrees of emotional distress. For another, the nurses believed that children suffer far less psychological distress than adults for comparable levels of pain. A cross-cultural study of both pain attitudes and reactivity to experimen- tally induced discomfort was conducted by Nayak, Shiflett, Eshun, and Le- vine (2000). They explored differences in beliefs about appropriate or nor- mative pain behavior, extending the research of Kodiath and Kodiath (1992), who found that patients in India reported less suffering and anger about lack of pain relief than individuals in the United States with similar levels of pain. Both males and females in India believed that overt expression of pain is less appropriate than did the U. Moreover, the Indian volunteers of both sexes kept their hand in the ice water longer than their American counter- parts. The authors suggested: The greater willingness to express pain in American society could be due to the belief that pain is bad, need not be endured, and should be quickly elimi- nated. In addition, in American society today, the medical profession has taken on the primary role of pain relief, which, combined with the widespread availability and use of analgesics, provides a powerful reinforcement for pain expression. A relatively small sample of dentists and patients from three ethnic groups (Anglo-American, Chinese, and Scandinavian), all living in the greater Seattle area, were interviewed about their ways of coping with pain (Moore, 1990). Anglo-American patients sought pills and injections, denial of pain, and reassuring clinical contacts. In contrast, the Chinese patients preferred salves, oils, creams, and com- 164 ROLLMAN presses and nontraditional medicine, although Chinese dentists (and the Scandinavian ones) shared the American preference for using pharmaceuti- cal treatments. Interestingly, although Scandinavian patients did not want to be treated with local anesthetics, many volunteered that they accepted this treatment for their dentist’s peace of mind. It is rare for anthropologists to go into the field in order to study pain behavior within an isolated cultural group. One exception is Sargent’s (1984) study, conducted in the mid-1970s, of the Bari- ba, a major group of about 400,000 persons living in Benin and Nigeria who are “notable for consistently demonstrating an ‘absence of manifest behav- ior’ when confronted with apparently painful stimuli such as childbirth, wounds, or initiation ordeals” (p.

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Crepitus may be an inci- dental finding buy 5mg clarinex mastercard allergy symptoms child, but it is also consistent with osteoarthritis and patellofemoral syndrome clarinex 5mg online allergy forecast usa. Pain and tenderness at the tibial tubercle in young individuals is consistent with Osgood- 94 Musculoskeletal Diagnosis Photo 1. Palpate posteromedial to the tibial tubercle approximately 2 inches below the joint line (Photo 2). This area is the pes anserinus, and it is the point at which the tendons of the sartorius, gracilis, and semitendinosus muscles attach to the tibia. These muscles can be remembered by the convenient pneumonic: Say Grace Before Tea. A bursa overlies the insertion of these tendons and can become inflamed. While the patient is still seated with legs hanging off the examining table, palpate the patient’s joint line between the femoral condyles and tibial plateau. Tenderness along the medial joint line suggests an injury of the medial meniscus or medial collateral ligament. Tenderness along the lateral joint line suggests a lateral meniscus or lateral collateral lig- ament injury. Next, palpate the popliteal fossa and appreciate the pulsation of the popliteal artery. Following this, test the muscles of the patient’s knee by having the patient extend the knee against resistance (Photo 3). This tests the quadriceps, which are innervated by the femoral nerve (L2–L4). Next, have the patient bring the ankle underneath the table (flexing the knee) against resistance (Photo 4). This tests the patient’s ham- string muscles, which are innervated primarily by the tibial portion of the sciatic nerve (L5, S1). The common peroneal portion of the sciatic nerve (L5–S2) innervates the short head of the biceps femoris. Table 1 lists the major movements of the knee, along with the involved muscles and their innervation. Knee Pain 97 Table 1 Primary Muscles and Innervation for Knee Movement Major muscle movement Primary muscles involved Primary innervation Knee flexion Hamstrings Primarily tibial, but also (semimembranosus, peroneal portion of semitendinosus, biceps sciatic nerve femoris). Knee extension Quadriceps (vastus Femoral nerve lateralis, vastus medialis, (primarily L4). With the patient still seated, test for stability of the medial collateral ligament (MCL). Next, secure the patient’s ankle in one hand and cup the patient’s knee with the other hand so that your thenar eminence is against the patient’s fibular head. Place a firm valgus stress on the patient’s knee by push- ing medially against the patient’s knee and pulling laterally against the patient’s ankle—this maneuver is performed in an attempt to open the medial side of his knee (Photo 5). If there is an MCL injury, there will be medial joint-line gapping that you will appreciate with the fingers that are cupped around the patient’s knee. When the valgus stress on the patient’s leg is relieved, the patient’s knee may be felt to “clunk” back together if there is an MCL tear. To test for a lateral collateral ligament (LCL) tear, apply a varus stress to the patient’s joint by pushing the patient’s ankle medially while pulling the patient’s knee laterally. Remember to keep your hand cupped around the lateral aspect of the joint in order to appreciate gap- ping, if present (Photo 6). Next, have the patient lie in the supine position while you check for an effusion. Look for a large effusion by pushing the patient’s patella superiorly and then quickly releasing it. If there is a large amount of fluid, the fluid will redistribute and push the patella into its former position. Knee Pain 99 you may need to milk the fluid from the suprapatellar pouch and the lat- eral side of the knee over to the medial side of the knee.

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When the knee is extended generic clarinex 5mg without a prescription allergy histamine, tient to use more external forces without having to expend dorsiflexion is reduced because the gastrocnemius mus- so much muscular effort generic clarinex 5mg mastercard allergy forecast orlando. Finally, dorsiflexion at the ankle can also be tested with the lower ankle in a free position. This shows Muscle contractures the functionally relevant dorsiflexion despite a possible The search for muscle contractures forms an important shortened triceps surae muscle with an overextended part of the neuro-orthopaedic examination. The examination must be performed slowly and Skeletal deformities steadily in patients with spasticity, since sudden move- As well as measuring the range of motion in the joints and ments can trigger spasms which can then be mistaken muscle contractures, the orthopaedist must also ascertain for muscle contractures. The patient’s position as he or depend on the position of the body, while primitive re- she enters the office is particularly informative. Nevertheless, the mobility of the trunk postures are also still present. The spine is examined with the patient in a sitting or In our experience, examinations under anesthesia are standing position. At the In patients with muscular dystrophy, the possibility hip, just shifting the range of motion in the direction of of pain must be taken into consideration in addition to internal rotation will reveal any increased anteversion. Consequently, even slight stretching is tion in which the greater trochanter shows maximum painful. A clinical parameter At the hip level, shortening of the flexors is com- for the torsion in the lower leg is the angle between the pensated for by hyperlordosis since, when the patient is knee axis and the malleolar axis with the knee in a flexed lying down, gravity forces the legs downward, producing position. If the other leg is flexed to its maximum extent, the pelvic tilt and compensatory Functional examination hyperlordosis are cancelled. The thigh of this other leg Any examination should, insofar as possible, include the then raises itself from the examination couch, thereby testing of functions such as walking, standing or sitting demonstrating the presence of a flexion contracture. Full in order to establish the functional consequences of the extension can be examined with the patient in the supine observed structural changes. The analysis of walking in position with the legs hanging freely over the end of the everyday clinical practice is essentially based on the prin- couch. The length of the knee flexors (hamstring muscles) ciples of gait analysis. While a basic clinical examination can readily be evaluated by flexing the leg at the hip by 90° is usually sufficient for a general assessment of simple and then stretching the knee out of the flexed position. Alternatively, the extended leg nature and extent of the functionally disruptive changes can be lifted off the couch and the maximum flexion at – together with details that are important for the treat- the hip measured. Standing on such patients only sink towards the floor to the point one leg for a fairly long period involves a higher degree where the knees press against each other, thus enabling of difficulty. These two tests can provide a rough as- them to stand in a stable position. As well as checking leg length and nally rotated legs: If the knees give way, they do so in the balance of the standing patient, the examiner also assesses direction of walking. But if they give way when pointing whether the hips and knees can be extended sufficiently straight ahead or outwards (as in patients with legs that and whether both legs are weight bearing. Patients with point straight ahead or outwards), the patients must bal- sitting problems of contractures in particular must be ance their upper body over the poorly controllable legs examined while seated. Ideally, the patient should sit on in order to restore their equilibrium. The orthopaedist a trunk-swinging or Duchenne limp that cannot be im- can now test whether the patient is able to maintain this proved by treatment. On the other hand, a pronounced position independently or how much additional external internal rotation during walking can be troublesome if the help with stabilization is required. Actual forward propulsion is no longer possible zontally without rotation, and the legs are spread apart as and walking is hampered. The trunk is aligned as straight as pos- that the aim of treatment is not a »normal« configuration sible over the pelvis in this position. This is a simple way of the musculoskeletal system, but rather one that is best of showing the extent to which movement restrictions for the patient. Examination of the patient legs can also simply be esthetically unappealing without in the lying position should not be forgotten, since these any functional impairment. Hemiplegic patients may dis- patients may lie for relatively protracted periods during like their typical hand position with pronation, flexion the day, and posturally-related deformities are common.

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The results of resection of the coali- Classification according to Blauth tion are usually good if the joint is actively moved post- Syndrome classification in two directions: longitudinal and operatively clarinex 5mg with amex allergy forecast provo utah. We usually leave the epidural catheter in place for The transverse axis refers to the affected toe (1 purchase clarinex 5mg online allergy medicine 12 hour, 2, 3, several days while administering intense physiotherapy. After the patient is discharged, movement of the rearfoot The longitudinal axis refers to the site of the duplica- must continue to be actively assisted on a daily basis for tion: distal phalanx, middle phalanx, proximal pha- several months. Super- numerary toes are usually most striking if they are not > Definition aligned in parallel with the other toes (⊡ Fig. The such protruding toes will cause problems when footwear supernumerary toe(s) can be in differing stages of is worn and are very unsightly, the decision to remove development. If the bifurcation occurs at the level of the metatarsals, the Occurrence, etiology toes will often show parallel alignment, but the foot will Polydactyly of the feet (and of the hands) is a relatively be much wider than normal. The incidence among the white when it comes to the provision of footwear (⊡ Fig. The incidence calculated for deviation often occurs at the metatarsophalangeal joint, the black population is 30:100,000, compared to causing both sections of the duplicated great toe to show 45:100,000 for Indians. Most cases of polydactyly varus alignment (congenital hallux varus, see chap- occur as an isolated deformity, unilaterally or bilater- ter 3. Polydactylies are not infrequently combined ally on the feet alone or on both hands and feet. An association seems to exist between condition is inherited as an autosomal recessive trait. Treatment Duplication of the 5th toe is the commonest abnormal- The ideal age to remove supernumerary toes is between ity. Simple resection of the surplus toes is involved either trisomy 21, trisomy 13 or Meckel syn- generally sufficient (particularly for the postaxial forms). The latter is a rare autosomal recessive disor- The surgeon should be careful to ensure that the scar der involving, in addition to the polydactyly, abnor- does not occur on the lateral edge of the foot, where it malities of the kidneys, liver and CNS. Although this is technically more difficult, it does result in a more stable and sturdier lateral foot margin. On the medial side, simple resection of the supernumer- ary toes is not usually sufficient, since a varus deformity is additionally present and the 1st metatarsal is often shortened. The deviation of the metatarsophalangeal joint occasionally needs to be corrected by means of an osteotomy (⊡ Fig. If the 1st metatarsal is severely shortened, a lengthening osteotomy with an external fixator may be necessary. After separation of syndactyly with scar-related adhesion year old girl. Left preoperatively, right after removal by chiseling of the on the great toe medially projecting part in the area of the 1st metatarsal head a b c ⊡ Fig. Female patient with polydactyly of the preaxial type gus is present due to the asymmetrically formed metatarsophalangeal (DP views). Boys are more Missing or incompletely formed web space between frequently affected than girls, and the right side is more two toes. Split Occurrence feet have also been observed in connection with tibial 3 Syndactyly of the feet, though not as common as syndac- aplasia. The autosomal dominant form with incomplete tyly of the hands, is not a rare deformity, and also occurs penetrance is always bilateral, while the unilateral form particularly in connection with polydactyly. The hereditary form is frequently associated Clinical features, diagnosis, treatment with cleft hand, possibly also with cleft lip and palate Although syndactyly is not associated with cosmetic or or with syndactyly and polydactyly, and possibly with functional disadvantages, the parents of the affected child deafness. The development of split foot starts on the 2nd or 3rd by the argument that other people are hardly ever aware ray and progresses in a distal to proximal direction. Surgical treatment is therefore strongly discouraged, because the risk of com- ⊡ Table 3. Postoperatively, it is not possible to keep the result- Type Features ing web space as dry as one between the fingers, ultimately leading to potential wound adhesions and scar formation, I 2nd–4th toes missing, normal metatarsals which can then (in contrast with the original syndactyly) II 2nd–4th toes missing, all metatarsals present, but cause functional problems (⊡ Fig. The defect is always greater at the distal end compared to An increased frequency of valgus deformity of the distal the proximal end.

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