By Y. Porgan. Ohio Dominican University.
He indi- cated that while he was incarcerated he frequently refused treatment be- cause "I didn’t want to be a bump on the log discount advair diskus 250 mcg with amex. As the drawings illustrate order 100mcg advair diskus visa, he had not mastered the tasks necessary to move from a child’s sense of dependency to an adult’s sense of competency 250mcg advair diskus for sale. The confu- sion that accompanies adolescence was exacerbated by an illness that gen- erates detachment over productiveness discount 100mcg advair diskus amex. Instead of finding success within his relationships, his work, and social interaction, he found success within his delusional beliefs. He could move houses by laying a hand on them—why would someone with that "power" desire the drudgery and responsibility that attended daily living? To prepare Dion for a future where responsibility, action, and reality is- sues outweighed the lure of an omnipotent delusional power (which he could call upon by refusing his medication), our focus centered on the growth of the self as a being separate from the dependency upon a "family unit" (his biological family, the hospital staff, etc. After months of art directives designed to strengthen his ego and expand his coping capacities, Dion announced, "I don’t really know how to do life. It was time to challenge the disease that had fixated him within adolescence for mastery. This is generally interpreted as a need to contain and delineate the ego boundaries. For this reason, the reinforcement of the body wall barriers parallels that of human functioning, as "the ego not only mediates between the individual and the environment but also mediates in- ternal conflict among various aspects of the personality" (Goldstein, 1984, p. It is in this image that Dion is able to reconcile unconscious feelings with determined statements and thoughts. In talking about his drawing he stated, "I know it’s good, but it’s hard and painful to learn new things. Individual sessions were no different: As we explored his early adolescence, withdrawal and retreat became his man- ner of coping with environmental stressors as outside support systems gave 226 Individual Therapy: Three Cases Revealed 5. Note that both the driver of the crane and the individual being flattened are projections of Dion. Throughout the discussion Dion processed the fig- ure under the ball as himself: "When I’m powerless I’m all curled up, shrunken. Utilizing this metaphor became an important re- minder for Dion both verbally and symbolically. It was no longer the drop- ping ball that held the power, but the person in charge; an individual could control environmental events in countless ways. This insight allowed Dion to take action, to become an individual with a sense of self that was not in- tertwined with his identity of the past (the outcast, the crazy one, the one who was isolative and withdrawn). By the 11th month Dion was taking an increasingly assertive role in the di- rection of therapy. In this drawing he has combined his past (at the age of 8) achievement of learning to swim with the process of learning new skills as an adult (in this case, jumping rope). If we recall his earlier works, the environments had a tendency to ap- pear chaotic and anxious. His drawings showed roads slanting upward and trees looming ominously overhead, with a paucity of social interaction and learning. The social contact in addition to the attainment of knowledge finds him as a cooperating community member. In our final month of therapy I thought it would be important for Dion to review the entirety of his artwork. He had, in many respects, illustrated a time line of not only fixation in childhood dependency and isolation but a progression toward adult affiliation and competency. In all, Dion had com- pleted a total of 65 drawings, which we reviewed in chronological order. A powerful intervention that often clarifies observation, this process allowed him the opportunity to witness the unfolding of his progression while view- ing the artwork as both observer and participant. Throughout the review his reflections ranged over his feelings ("I blamed them [friends] for moving away. I hated them for that"), his thoughts ("I may not be that [a therapist]; maybe I’ll be a sponsor, I can help others that way"), and his relationship with me over the course of our sessions (the ego ideal—the desire to be a therapist—that he no longer found essential as he acquired his own ego identity).
The abstracted clinical information of 27 patients was presented to two other otolaryngologists purchase advair diskus 250 mcg mastercard, and the same ques- tionnaires were administered before and after reviewing the sinus CT cheap advair diskus 250mcg online. Sinus CT altered dichotomous treatment decisions (surgical versus non- surgical) by the surgeon in one third of patients (9/27) and there was a tendency to offer the surgical treatment after reviewing the sinus CT more than before advair diskus 500 mcg low cost. The agreement among surgeons with clinical history and physical examination alone was poor but was much improved after reviewing sinus CT generic 250mcg advair diskus with mastercard. The results of this study indicate that sinus CT provides pivotal objective information that affects treatment decisions and improves the agreement of treatment plans among surgeons (limited evidence). Special Case: Cost-Effectiveness Analysis in Chronic Sinusitis There has been no CEA for chronic sinusitis from the U. Only one recent study from Taiwan assessed cost utility analysis of endoscopic sinus surgery. It measured the cumulative cost of treating chronic sinusi- tis with FESS based on severity of disease. The study revealed an average cost-utility ratio of $70,221 and a high cost-utility ratio of $103,872 (after conversion to U. The cost structure in their study showed that 66% of the total cost was the operation fee. Endoscopic sinus surgery is pri- marily performed on an outpatient basis in the U. Evidence is lacking in this field, and future research is needed (insufficient evidence). Health care costs for patients with chronic sinusitis were investigated in health maintenance organizations (HMOs) in the state of Washington. This study found that adult patients with chronic sinusitis have more nonurgent outpatient visits and fill more prescriptions than adult patients without a history of chronic sinusitis, not including endoscopic sinus surgery. The Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 229 Patients present with acute sinusitis symptoms Use clinical prediction rules or risk factors to differentiate bacterial and viral infection Suspect bacterial sinusitis Uncomplicate viral infection (high probability for ABS) (intermediate to low probability) ABX treatment Decongestant or anti-allergy Rx if h/o allergy Good clinical response Poor response Good clinical response Poor response No imaging study Screening sinus CT No imaging ABX depends on clinical exam Positive CT Negative CT Good clinical response Poor clinical response Change ABX Consider other diagnoses No imaging Screening sinus CT Positive CT Negative CT Change ABX Consider other diagnoses Figure 12. Decision tree for imaging evaluation and management of acute bacterial sinusitis (ABS). Take-Home Figures Decision trees for imaging evaluation and management of acute and chronic sinusitis are shown in Figures 12. Noncontrast screening sinus CT 5-mm-thick coronal images every 10mm 140KVP, 200MA Indications: sinusitis symptoms not responding to medical treatment Diagnosis of sinusitis is in doubt, rule out sinusitis Recent sinusitis, need to evaluate response to treatment 2. Patients with history of chronic sinusitis presented with sinusitis symptoms Treat with ABX and other medical management if applicable (i. If CT correlates w Search for underlying Controversial symptoms consider systemic disease surgery If refractory to the maximum medical Rx, a patient desires, consider surgery Figure 12. Indications: patients require imaging-guided monitoring for endoscopic sinus surgery for skull base lesions or complex sinus surgery Future Research • Randomized controlled trial of antibiotic for patients with mucosal thickening only on CT in order to determine if this group of patients benefits from antibiotic treatment for acute sinusitis. Summary Acute sinusitis • Despite inaccurate clinical diagnosis of acute or chronic sinusitis, the initial treatment decision is based on clinical diagnosis. Imaging study is indicated when patients failed to respond to the initial treatment. Chapter 12 Imaging Evaluation of Sinusitis: Impact on Health Outcome 231 Chronis sinusitis • For patients with clinical diagnosis of chronic sinusitis, imaging study is indicated when patients failed to respond to medical management, in order to determine if symptoms are related to sinusitis, or to evaluate strutural abnormalities. Usefulness of simple paranasal sinus radiographs and axial computed tomography in the diagnosis of chronic sinusitis (in Spanish). The impact of sinus computed tomography on treatment decisions for chronic sinusitis. Which patients with head injury should undergo imaging in the Issues acute setting? What is the sensitivity and specificity of imaging for injury requir- ing immediate treatment/surgery? Is the approach to imaging children with traumatic brain injury different from that for adults? Head injury is not a homogeneous phenomenon and has a complex Key Points clinical course.