Medical Aspects Notes 1 Medical Aspects Notes CASP 532 Medical and Physical Aspects of Disability Dr. Jerry Fischer, CRC, LPC Professor Counseling and School Psychology University of Idaho 2000 Medical Aspects Notes 2 TABLE OF CONTENTS Psychosocial Aspects of Chronic Illness and Disability 3 Nervous System 7 Traumatic Brain Injury 10 Stroke (Cerebrovascular Accident) 15 Cerebral Palsy 18 Seizure Disorders (Epilepsy) 22 Multiple Sclerosis 25 Spinal Cord Injuries 28 Spina Bifida 31 Motor Neuron Diseases (Muscular Dystrophy) 35 Post Polio Syndrome 38 Auditory 40 Hearing Impairments 42 Visual 46 Visual Impairments 48 Blood and the Immune System 50 Hemophilia 53 Sickle Cell Anemia 55 HIV/AIDS 57 Endocrine Disorders 60 Musculoskeletal and Connective Tissue Disorders 65 Fractures 69 Carpal Tunnel Syndrome 71 Low Back Pain 73 Amputations 76 Arthritis 79 Cardiovascular 82 Cardiovascular and Peripheral 84 Respiratory 87 Asthma 92 Allergies 94 Renal and Urinary Tract 96 Dermotologic 100 Burns 102 Gastrointestinal Disorders 104 Cancer 108 Alcohol Abuse/Dependency 113 Drug Abuse/Dependency 116 Eating Disorders 119 Obesity 122 Affective Disorders 124 Delusional Disorders 127 Developmental Disabilities 129 Personality Disorders 132 Schizophrenic Disorders 134 Specific Learning Disorders 140 Medical Terminology Rules 144 Medical Terminology 145 Prefixes 145 Suffixes 148 Medical Aspects Notes 3 Roots 150 Medical Charting Abbreviations 158 Medical Symbols 165 Psychiatric Rehabilitation 166 Medications for Schizophrenia 169 Medications for Delusional Disorders 171 Medications for Bipolar Disorder 171 Medications for Depression 173 Medications for Anxiety Disorders 175 Medications for Cerebral Palsy 177 Medications for Seizure Disorders 177 Lymphocytes 179 VR Eligibility Determination 180 Case Example (Cardiovascular) 183 Case Example (Learning Disability) 185 Case Example (Amputation) 187 Case Example (Low Back Pain) 189 Case Example (Arthritis) 191 Case Example (Schizophrenia) 193 AIDS Update 196 Medical Aspects Notes 4 CASP 532 Dr. Jerry Fischer Psycho-social and Functional Aspects of Chronic Illness and Disability Learning objectives; students will be able to: 1. Understand the impact of medical/physical conditions on psycho-social aspects of an individual. 2. Identify factors which either strengthen or lessen the degree of functional impediments caused by a disability. A medical condition must be considered in the context of the effect of its, diagnosis, symptoms, and treatment on all aspects of the individual's life, specifically on the individual's capacity to function within his or her environment. A. Stress in Chronic Illness and Disability Stress is less pronounced when individuals are able to maintain confidence in their ability to maintain some control over their destiny and believe that changes, although inevitable, are manageable. THEY CAN COPE. Stress caused by potential threats to: 1) life and physical well-being 2) body integrity and comfort as a result of illness or disability itself, diagnostic procedures, or treatment 3) independence, privacy, autonomy, and control 4) self-concept and fulfillment of customary roles 5) life-goals and future plans 6) relationships with family, friends, and colleagues 7) the ability to remain in familiar surroundings 8) economic well-being B. Self-Concept and Body Image Changes in appearance, capabilities, or functional status can contribute to an altered body image, and thus, to an altered self-concept. Medical Aspects Notes 5 C. Uncertainty Disabilities vary greatly in their impact upon functional capacity, hence, for some disabilities the inability to predict the future becomes more disabling than the actual physical consequences of the condition. Insecurity about the course of a disability may be reflected by significant others who, in order to protect themselves from future loss, withdraw. D. Stigma Societal expectations define, by general standards, the appearance, activities, and roles that are acceptable. Individuals who deviate from expectations in any of these areas are labeled as different by the majority and, thus, may be stigmatized. (mark of disgrace) E. Emotional Reactions to Chronic Disease or Disability 1. Grief: pain as individuals attempt to accept the loss they have experienced. 2. Fear and anxiety: often places individuals in a state of panic that renders them unable to act 3. Anger: externally focused or internally 4. Depression: helplessness, hopelessness, apathy, dejection, and discouragement. Symptoms include sleep disturbances, changes in appetite, difficulty concentrating, and withdrawal 5. Guilt: punishment for previous transgressions F. Coping Strategies Effective coping must be viewed in the context of each individual's personal background and experiences, life situation, and perception of the circumstance. Individuals tend to use coping strategies that have worked in the past. 1. Denial: non-acceptance of the condition and its implications 2. Avoidance: accepts situation but actively ignores ramifications 3. Regression: return to a state of dependency 4. Compensation: counteract limitation by becoming stronger or more proficient in other areas 5. Rationalization: excuses for not reaching goals or accomplishing tasks 6. Diversion of feelings: diverting unacceptable feelings or thoughts in to socially acceptable ones Medical Aspects Notes 6 G. Chronic Illness and Disability Throughout the Life Cycle infancy and early childhood school-aged child adolescence young adulthood middle age older adulthood H. Other Issues in Chronic Illness and disability 1. Invisible disabilities (hidden disabilities): there is no atypical appearance or cues to indicate limitations associated with disability, those who interact have no basis to alter expectations with regard to the individual and his or her functional capacity 2. Sexuality: Each person needs intimacy. Disability may change an individuals' perceptions of themselves as sexual beings, or change others perceptions, but does not change the inherent need for closeness 3. Family adaptation: most important factor in adjustment to disability. Members may provide emotional support, physical care, supervision, transportation, many services 4. Adherence with Prescribed Treatment and Recommendations: nonadherence to recommendations may be an attempt to exert self-determination, to regain a sense of autonomy and control, and to claim some mastery over individual destiny (suicide) 5. The economic consequences of illness or disability may also cause a reverse reaction. If an individual is receiving disability benefits and little opportunity for satisfactory employment, he or she may not follow recommendations that increase capacity to return to work, thereby decreasing or eliminating benefits. Professionals' goals should attempt to understand the underlying problem and motivations of individuals and help them to make necessary adjustments and adaptations to maximize functional outcomes. Rather than criticizing those who are ill or disabled for disinterest, a lack of motivation, or failure to follow recommendations. 6. Patient (Client and Family) Education: an individuals' understanding of their condition and treatment is one of the basic components of self- determination and responsible care Medical Aspects Notes 7 K. Functional Aspects of Chronic Illness and Disability The extent to which the condition is an impediment depends to a great extent on the individual's perceptions of the condition; the environment; and the reactions of family, friends, and society in general. The severity of the condition as measured by diagnostic tests does not always indicate the severity of the functional impairment, nor is the individual's ability to function always directly correlated with the severity of the condition itself. 1. Psychological Implications: ever present and influence an individual's response to disability, sometime the factors are symptoms of the condition itself 2. Lifestyle Implications: include transportation, daily schedules, need for rest and activity, recreation, sexuality, and privacy 3. Social Implications: social well being is based on emotionally satisfying experiences in social activities with those within the individual's social group. 4. Vocational Implications: Work involves more than remuneration for services rendered and does not necessarily include only activity related to financial incentives. Work provides a sense of contribution, accomplishment, and meaning to life. Consequently, the loss of the ability to work extends beyond financial considerations to social and psychological well-being. The loss of the ability to work means more than the loss of income, it also means the loss of a social valued role. For many individuals, work is not only a major part of their identity, but also a source of social interaction, structure, and purpose in life. The individual's capacity to function at a job can depend on cognitive, psychomotor, and attitudinal factors, as well as on the physical aspects of disability. An accurate assessment of an individual's capacity to return to work consists of more than evaluation of physical factors alone. Success or failure at work is often determined by factors other than physical skill or ability. The individual's fear of re-injury, vocational dissatisfaction, or legal issues can hamper the return to work. Medical Aspects Notes 8 NERVOUS SYSTEM Normal Structure neurons cerebrospinal fluid (CFS) cell body ventricles dendrites cerebrum axon cortex neuro-transmitters motor synapse sensory Central Nervous System associational matter frontal lobe white parietal lobe gray temporal lobe reflex occipital lobe basal ganglia Wernicke's area extrapyramidal Broca's area cranium cerebellum cranial bones brain stem vertebrae reticular formation cervical (7) Peripheral Nervous System thoracic (12) cranial nerves lumbar (5) spinal nerves sacrum sensory nerves coccyx afferent motor nerves dura matter efferent arachnoid membrane somatic pia matter autonomic nervous system epidural space sympathetic subdural space parasympathetic arachnoid space Disorders Traumatic brain injury post-traumatic hydrocephalus closed head injury residual effects edema ataxia hematoma dystonia open (penetrating) head injury dyskinesias edema dysarthria concussion apraxia of speech cerebral contusion aphasia coma nonfluent Glasgow Coma Scale fluent persistent vegetative state Broca's global intercrannial hemorrahage Wernick's receptive hematomas diplopia epidural hematoma hemianopia subdural hematoma agnosia post-traumatic epilepsy Medical Aspects Notes 9 Disorders continued tinnitus Jacksonian anosmia complex-partial (psychomotor) cerebrovascular accident (CVA) multiple sclerosis thrombus exacerbation cerebral thrombosis remission cerebral embolism paresthesia cerebral aneurysm diplopia transient ischemic attacks vertigo left hemiplegia intention tremor aphasia scanning right hemiplegia dysphagia visual spatial deficits incontinence anosognosia urinary retention cerebral palsy Parkinson's Disease spasticity secondary parkinsonism hypertonia bradykinesia ataxia akinesia dyskinesia micrographia athetosis resting tremor choreoathetosis meningitis contractures encephalitis amyotrophic lateral sclerosis (ALS) Gullain-Barre Syndrome motor neurons Acute Post infectious atrophy Polyneuropathy) Huntington's Chorea post polio syndrome progressive dementia spinal cord injuries epilepsy atrophy Grand Mal quadriplegia generalized paraplegia tonic-clonic seizure autonomic dysreflexia Petit Mal decubitis ulcers absence seizures contractures partial seizures focal seizures Diagnostic skull/spine x-rays lumbar puncture CAT scan (cerebro-spinal fluid analysis, Brain scan spinal tap) positron emission transaxial electroencephalography (EEG) tomography (PET scan) electromyography MRI neuro-psychological tests myelography Halstad Reitan cerebral angiography Luria-Nebraska digital venous subtraction angiography Medical Aspects Notes 10 Treatment TBI MS burr holes muscle relaxant craniotomy antispasmodics diuretics anticholinergic CVA cholinergic antihypertensives Parkinson's L-dopa anticoagulants SCI gait training halo brace subluxation Epilepsy anticonvulsant anti-epileptic status epilepticus alcohol PsychoSocial compensatory activities dependency social interactions privacy continuous re-adaptation family support uncertainty misinterpretation hostility misperception of limitations anger conflict of expectations depression intoxication remorse afraid of seizures self-recrimination over protective retribution eye contact resentment disinhibition impulsivity Life Style loss of privacy sexual function flashing lights reflex erections fatigue spasms Vocational progressive vs. stable communication job stress temperature extremes Medical Aspects Notes 11 TRAUMATIC BRAIN INJURY Initial Interview Questions: 1. Do they have physical problems (e.g., balance, lifting, walking, strength, etc.)? 2. Do they have any sensory or motor problems (e.g., vision, coordination, pain perception, hearing, etc.)? 3. do they have any cognitive problems (e.g., memory, writing, organizational and planning ability, communication, attention, reading)? 4. Do they have any social/behavioral problems (e.g., taking initiative, inflexibility, irritability, social judgment, maturity, social awkwardness, impulsiveness, aggressiveness)? 5. Do they have any emotional problems (e.g., anger, anxiety, depression, etc.)? 6. Do they display sudden changes in behavior or emotion (temper outbursts, crying without cause, etc.)? 7. Do they have problems in activities of daily living particularly in handling money? 8. Do they experience seizures? 9. Are they currently under treatment? Do they feel they are continuing to improve? 10. What is their job expectation and what does their family expect? 11. Do they have a close supportive caregiver? 12. Do they have any legal issues associated with their accident that may interfere with VR? 13. How long were they unconscious? Observations During Initial Interview: 1. Is there paralysis or other physical problems? 2. Is their speech affected? Medical Aspects Notes 12 3. Do they have problems with mobility/gait? 4. Do they use assistive devices for mobility? 5. Do they appear to have memory problems? 6. Is there any problem with social maturity or awkwardness? 7. Do they appear angry, depressed, anxious, or exhibit low self-esteem? 8. Did they exhibit appropriate dress and grooming? Common Functional Limitations: 1. Balancing 2. Lifting 3. Walking 4. Strength 5. Coordination 6. Vision 7. Pain and headaches 8. Hearing 9. Memory 10. Organizational and planning ability 11. Communication skills 12. Attention span/distractibility 13. Writing skills 14. Reading skills 15. Visual-spatial skills 16. Lack of initiative 17. Inflexibility Medical Aspects Notes 13 18. Irritability 19. Social judgment 20. Maturity 21. Social awkwardness 22. Impulsiveness 23. Feelings of isolation 24. Aggressiveness 25. Concrete thinking 26. Anger 27. Depression 28. Anxiety 29. Low self-esteem 30. Behavioral problems 31. Suspiciousness 32. Low self-care skills 33. Low safety skills 34. Money handling problems 35. Inability to carry out previously learned tasks and inability to learn new tasks 36. Slowness Vocational Impediment Connection: Normally it is not difficult to determine that an individual with TBI has a vocational impediment. Individuals with TBI often have numerous obvious physical complications and resulting functional limitations which can easily be tied to inability to perform job tasks. If they have worked before injury they may have tried to return and been unable to perform adequately. They often cannot generalize prior learning in new situations. Medical Aspects Notes 14 The counselor should be careful to assess individuals who exhibit no obvious functional limitations. They may present themselves quite well yet upon assessment, severe impediments to employment in cognitive, social, and behavioral areas may surface. Goal of Employment Considerations: The most difficult part of case management for individuals with TBI is to determine employability. Cognitive rehabilitation may return an individual to premorbid functioning. However, generally the length of time an individual has been unconscious due to head injury gives some indication as to rehabilitation gain. Often the individual presents difficulties in terms of processing (i.e., doesn't understand, forgetful, anxious, lack of insight into their condition). The counselor should try to include the family, personal attendant, or nursing home/hospital social workers in the intake interview. Physical appearance often belies many subtle disorders of significance for rehabilitation planning. Individuals with TBI may present themselves with one or two major problems which seem to be most significant in terms of rehabilitation, (e.g., speech, ambulation, or coordination), however, the counselor can expect that other areas affected may, in fact, be as significant or more significant in terms of long- term employment (e.g., executive functioning, short-term memory, distractibility, and fatigue). Consideration should be given to the expectations of the individual and family. In some cases individuals have unrealistic expectations of their abilities or aptitudes which should be explored in depth. The family is a good source of information about the individual, but in a very few number of cases they may be a hindrance, when they cling to unrealistic desires to return the individual to pre-injury work. Situational assessments and on-the-job evaluations will be more helpful in assessing work related skills than evaluations that focus on aptitudes. IPE Considerations: Because much of the neurological recovery generally occurs in the first 6 to 12 months after injury, it may be wise to delay a thorough assessment or work related services until later in the recovery process. Working as a team is very important. Include family, health care professionals, rehabilitation professionals (counselors, Medical Aspects Notes 15 evaluators, placement specialists, and independent living specialists), and other agency professionals involved with the client (e.g., mental health professionals, worker compensation professionals, social service professionals, and social security professionals). 1. Accommodation vs. remediation. Try to deal with the situation the way it is versus the way one thinks it should be or wants it to be. 2. Training on specific job skills is generally needed. Transfer of skills can be questionable for individuals with TBI. Attempts should be made to focus on the exact skills needed. The best approach may be on-the-job training with a job coach. 3. Consideration of job site engineering or accommodation as needed. 4. Follow-up after employment may be longer than traditionally done with other disabilities. 5. Focus on accommodation strategies to learn job skills. Learn alternative ways to accomplish tasks (e.g., work aids, checklists, calendaring, and time scheduling). Medical Aspects Notes 16 STROKE (Cerebrovascular Accident) Initial Interview Questions: 1. Do they have any residual weakness or problems with balance/coordination? 2. What extremities have been affected? 3. Any problems carrying out activities requiring hearing, vision, strength, or ambulation? 4. Any loss of specific skills (e.g., speech, driving, reading, writing, etc.)? 5. How independent are they in activities of daily living (e.g., feeding, toileting, shaving, etc.)? 6. Do they feel differently about themselves since the stroke (e.g., mood fluctuations, anger, depression, etc.)? Do other people treat them differently? 7. Any problems with memory or concentration? 8. Have they made any poor decisions lately? 9. Any changes in eating or sleeping habits? 10. Do activities take longer to complete now? 11. Do they feel they are still improving? 12. What medications are they taking, and what are the side effects? Observations During Initial Interview: 1. Is their mood appropriate? Exaggerated, depressed, angry? 2. What is their general physical appearance? 3. How is their gait? 4. How is their expression and reception of speech? 5. Can they write legibly? 6. Do they appear to have problems with vision? Medical Aspects Notes 17 7. Do they maintain eye contact? 8. Are there any obvious memory problems? Were they oriented as to time and place? 9. Did they use devices for mobility? 10. How was their self image? 11. Was their dress, grooming, and hygiene appropriate? Common Functional Limitations: 1. Stamina 2. Strength 3. Mobility 4. Mood and/or behavior changes 5. Attention, concentration, memory 6. Decision making 7. Impulse control 8. Complex skills 9. Motor control 10. Speed 11. Behavior 12. Social skills 13. Personality changes 14. Communication skills Vocational Impediment Connection: Usually the functional limitations resulting from a stroke are numerous and one can easily show a connection between those and vocational problems. Many times the individual has worked Medical Aspects Notes 18 before and cannot return to their job or they need special help in order to return to it. Primarily the counselor needs to look at the communication skills and residual physical capacities. Stamina and emotional problems can also contribute. Goal of Employment Considerations: The counselor usually needs some medical information suggesting stability (a reasonable prognosis). Consider if the individual will alter risk factors that will exacerbate the condition (e.g., smoking, drinking, diet, and exercise) and to what extent they will comply with a medical regimen. Ascertain the degree of family support and everyone's perceptions of the disability. IPE Considerations: Working as a team is very important. Include the family, health care professionals, rehabilitation professionals (counselor, evaluator, placement specialist, independent living specialist), and other agency professionals involved with the client (e.g., mental health professionals, worker compensation professionals, social service professionals, and social security professionals. 1. Accommodation vs. remediation. Try to deal with the situation the way it is versus the way one thinks it should be or wants it to be. 2. Consider short term vs. long term training. 3. Follow medical recommendations. 4. Modify risk factors. 5. Consider job site engineering or accommodations and focus on returning to work with former employer. 6. Follow-up after job obtained may need to be longer than traditionally done with other disabilities. Medical Aspects Notes 19 CEREBRAL PALSY Initial Interview Questions: 1. Have them describe the specific difficulties they have in muscle/reflex control (hip, feet, wrists, elbow, fingers, facial). 2. Are there problems with speech? 3. Do they experience specific difficulties in ambulation, coordination, sitting, balance, standing, dexterity, etc.? 4. What do they do in a typical day? 5. What kind of assistance do they receive in carrying out activities? 6. What kind of accommodation strategies do they use to overcome difficulties? 7. What does their family expect of them? 8. What do they expect of themselves? 9. What do they think they need to overcome? 10. What do they expect to do in terms of a job? 11. What do they see their assets being to achieve the vocational goal? 12. What types of assistive devices do they use? 13. If they use a wheelchair, has it been properly fitted by professional personnel? 14. What types of physical accommodations have they made? 15. Do they have a personal care attendant and if so, for what activities? 16. How long can they carry on activities before becoming fatigued? 17. What do they do socially? 18. What difficulties do they have in activities of daily living (e.g. grooming, bathing, food preparation, eating, dressing)? Medical Aspects Notes 20 19. Have they had respiratory, bowel and/or bladder difficulties? 20. Are they able to operate a motor vehicle? What modifications are necessary? Observations During Initial Interview: 1. Do they appear to be knowledgeable about what they can and cannot do? 2. How much prompting or leading is necessary in carrying out basic interview questions? 3. What is their cognitive status in processing information and answering questions in a relevant fashion? (correctness, understanding of VR process etc.) 4. How do they appear physically? Are they able to sit or stand for any extended period of time? Ambulation? 5. Did they use assistive devices - what type? 6. Did there appear to be any problems with speech clarity? 7. Did their grooming, dress and hygiene appear appropriate? Common Functional Limitations: 1. Physical: a. stamina b. strength c. pushing, pulling pressing d. climbing e. coordination f. speed g. muscular control h. ambulation i. balance j. standing k. stooping, bending l. transfers m. writing n. pulmonary o. bowel and bladder p. pain q. driving Medical Aspects Notes 21 r. need for personal care attendant s. activities of daily living (eating, cooking, dressing, personal hygiene) 2. Language and Communication (75% of the cases will have some affected language communication disorders). a. hearing disorders b. auditory and visual comprehension disorders c. distractibility d. weakness or in coordination of speech mechanism 3. Psychosocial a. cognition 1) verbal perception 2) verbal receptive 3) verbal expressive 4) visual perceptual 5) visual motor b. memory c. school achievement d. acquisition retention, interpretation and application of information e. social isolation f. dependency g. work personality 4. Complications a. contractures (joint limitations) b. bowel and bladder incontinence c. dental problems d. osteoporosis e. degenerative joint disorders due to poorly aligned joints f. scoliosis g. respiratory infections due to inefficient swallowing and compromised cough reflex. 5. Other commonly associated problems or disabilities a. learning disabilities b. developmental disabilities c. visual or hearing problems d. independent living skills e. seizures f. fatigue g. problem solving deficits h. lack of support systems Vocational Impediment Connection: Generally, because of the diffuse nature of this disability, Medical Aspects Notes 22 the individual will have many functional limitations and the connection between their functional limitations and vocational problems is easy to make. The counselor can attempt to show the difficulties the individual has had in past vocational endeavors because of the specific functional limitations or show how the limitations will limit their vocational choices in the future. Another way to show the connection is that preparation for employment (attainment of post-secondary training for example) may be quite difficult for these individuals. The counselor might also tie their limitations to the general area of vocational goals stated by the client. There are a host of ways to make this connection. If the individual has a seizure disorder, all of the limitations associated with seizure disorders and working with machinery, driving, etc. must be taken into account. Generally, you will find that physical problems will be the easiest to establish a vocational impediment. The cognitive and psychosocial issues are equally important in the vocational impediment. The major cognitive psychosocial issues relate to family support, community opportunities, and realistic vocational choice. Also, individuals with cerebral palsy have restricted social opportunities and so may appear to be somewhat dependent and egocentric. In addition, a family dynamic of protection of the individual from some of the problems in daily living may pose a problem to which the counselor should be sensitive. Goal of Employment Considerations: It is important to assess the extent of the physical limitations as they relate to the necessary job skills in jobs for which the individual qualifies. When individuals lack the necessary functional ability to qualify for a job, the counselor needs to look at potential training programs which might allow the individual to enter occupations appropriate to their limitations. The key at that point is an assessment of whether the individual has the potential to complete the training. Another possible consideration is the support and expectations of the family and willingness to allow the individual to experience increasing levels of independence and separation from the family. IPE Considerations: 1. Thoroughly evaluate and arrange necessary assistive devices (e.g. speech, mobility, computers, and electronic aids, etc.). Medical Aspects Notes 23 2. Promote healthy activity levels and routine exercise/- physical therapy programs. Very important for primary body functions as well as mental health. 3. Consider job accommodation and rehabilitation engineering. 4. Relocation assistance to independent living setting or to be closer to work site. 5. Counseling to help them develop a realistic goal and possibly necessary work related behaviors. 6. Make arrangements personal care attendants as needed. Medical Aspects Notes 24 SEIZURE DISORDER (EPILEPSY) (Tonic-Clonic, Absence, Simple Partial, and Complex Partial Seizures) Initial Interview Questions: 1. Have them describe the seizures including the cause if known. 2. How often have they experienced the seizures and how long are they incapacitated following the seizure? 3. How often do the seizures occur -What time of day- Are there preceding events? 4. Do they have a warning aura? 5. Are they currently under the care of a physician knowledgeable about the disease? 6. What medications are they on and what are the side effects (e.g., drowsiness, speech problems, concentration, gum disease)? Is the individual following the medication regime as described. 7. How has the disability affected past work or school? 8. Do they have a valid diver's license? 9. What restrictions have their physician given them (e.g., avoiding heights or dangerous equipment, etc.)? 10. Have them describe their feelings about their disability and how do they think others feel about their disability? Observations During Initial Interview: 1. Were there any seizures observed? 2. Does their mood seem affected (possibly by the disability or medications)? Does there appear to be deficits in social skills, maturity, etc.? 3. Are their motor functions impaired? 4. Is there speech impairment (slurring/slow pace)? 5. Are there any memory problems? Medical Aspects Notes 25 Common Functional Limitations: 1. Climbing 2. Balancing 3. Motor coordination 4. Eye/hand coordination 5. Wet and humid conditions 6. Noisy conditions 7. Memory 8. Attention span 9. Speed on activities 10 Vehicle operation Vocational Impediment Connections: If the individual has a seizure disorder consider the limitations associated with seizure disorders and working with machinery, driving, etc. must be taken into account. Generally, you will find that physical problems will be the easiest to establish a vocational impediment, but the psychosocial issues are equally important in the vocational impediment. The major psychosocial issues relate to family support, community opportunities, and realistic vocational choice. Consider if the individual has had restricted social opportunities and may appear to be somewhat dependent. In addition, a family dynamic of protection of the individual from some of the problems in daily living may pose a problem to which the counselor should be sensitive. Goal of Employment Considerations: The counselor should consider if the seizures are controllable for the particular employment goal. Ascertain how the individual deals with following their medication regimen and other medical advice prescribed. Consider if the client has warnings (auras) before seizures and the nature of the employment goal. Ascertain how long the recovery period is after the seizure. IPE Considerations: Medical Aspects Notes 26 1. Possible adjustment counseling to assist the individual in adapting to a work environment and co-workers, or to help the individual cope with the attitudinal barriers of their disability. 2. Heavy emphasis on placement. Strong job-seeking-skills- training to learn how to sell themselves. Selective placement (possibly to include on-the-job training, on-the- job evaluation, or transitional employment). 3. Allow for close medical involvement including routine check- ups and properly followed medical advice (preferably by a neurologist with a substantial background in dealing with epilepsy). 4. Carefully choose an employment goal taking into account all of the limitations and the seizure activity of the individual. Medical Aspects Notes 27 MULTIPLE SCLEROSIS Initial Interview Questions: 1. Does the individual have trouble breathing? 2. Does the individual have trouble with bowel and/or bladder control? 3. Does the individual require a personal attendant and, if so, for what activities? 4. Does the individual experience a loss of muscle functioning and, if so, where? 5. Does the individual have problems with stamina? 6. Does the individual have any speech difficulties? 7. Does the individual use any assistive devices and, if so, describe? (e.g., wheelchair, scooter, braces, crutches, etc.). 8. Is the individual able to operate a motor vehicle and what modifications are necessary? 9. Have the individual describe periods of exacerbation and remission? 10. Is the individual having any visual problems and, if so, describe? 11. Has the individual ever had any seizures? Observations During Initial Interview: 1. Did the individual utilize assistive devices and, if so, what type? 2. How did the individual's mobility appear to be? 3. Did there appear to be any problems with speech clarity? Common Functional Limitations: 1. talking 2. writing 3. walking Medical Aspects Notes 28 4. climbing 5. balancing 6. stooping 7. kneeling 8. crouching 9. lifting 10. twisting 11. reaching 12. fingering 13. motor coordination 14. eye-hand-foot coordination 15. stamina 16. strength 17. working in cold conditions 18. working in heat conditions 19. working in conditions where the temperature changes frequently 20. working in wet, humid conditions 21. vehicle operation Vocational Impediment Connection: Since multiple sclerosis has an onset in the twenties and thirties, the majority of persons will be either competitively employed or engaged in homemaking at the time of onset. The extent to which multiple sclerosis creates a vocational impediment during the early stages of the disease depends primarily on the type of occupation in which the person is engaged. Persons engaged in some professional, technical, managerial, clerical, and sales occupations may not encounter any specific vocational impediment. On the other hand, for those engaged in some agricultural and industrial occupations even Medical Aspects Notes 29 minor dysfunctions in coordination, dexterity, balance, gait, and muscle strength may have vocational impediment implications. However, generally in all cases, since there is no known cure or effective treatment for multiple sclerosis, it is likely to cause a vocational impediment in the near future. Goal of Employment Considerations: Since most persons are either employed or engaged in homemaking at the time of onset, the basic vocational rehabilitation strategy is one of maintaining current employment. This strategy is most readily achieved using rehabilitation engineering, job modification and restructuring, and assistive devices. Current employment in professional, technical, managerial, clerical, sales, and homemaking are generally conducive to rehabilitation gain because cognitive functions remain intact and physical demands can be altered with rehabilitation engineering approaches. Retention of employment in agriculture and industrial occupations tends to be more problematic because of the motor requirements involved. A thorough job and task analysis of current employment will usually disclose the extent to which rehabilitation engineering approaches can be applied. Close work with the employer will also indicate whether transfer into other jobs within the firm is possible with or without some type of training. Although it is tempting to consider the rate of progress of the disease in determining success in occupations, this is pointless everyday practice. There is no meaningful way to estimate rehabilitation gain in individual cases, particularly when the person comes to vocational rehabilitation early in the course of the disease. IPE Considerations: 1. The person with multiple sclerosis has a progressive, incurable fatal disorder. Coping with this is a major issue both for the person and family members. At a minimum, referral and involvement with a support group should be considered. Referral for mental health counseling may also be considered. If indicators are present, possibly a person should be monitored for signs of depression and suicidal thoughts. 2. Clear and explicit plans for post-employment services should be developed at the time the initial vocational rehabilitation case is closed. Additional services will typically be required as the person's physical functioning Medical Aspects Notes 30 deteriorates. 3. Consider involving the individual in support groups. 4. When establishing the job goal or specific work site, consider the individual's need for rest periodically. 5. First thought should be given to maintaining current employment. 6. Consider rehabilitation engineering to include job and worksite modifications. Medical Aspects Notes 31 SPINAL CORD INJURIES Initial Interview Questions: 1. What caused the disability and what kinds of treatment have they had? 2. At what level is the injury (e.g., sacral, lumbar, thoracic, cervical)? 3. Are there any x-rays? Where can the medical records be found? 4. What other limbs or functions are impaired by the injury (e.g., legs, hands, arms, breathing, bowel, bladder, sexual functioning, etc.)? 5. What kinds of problems do they have in daily activities: a. personal hygiene (bathing, grooming, bowel and bladder functions) b. range of ambulation and assistive devices used: wheelchair, braces (ankle foot orthoses (AFO) or long leg orthoses (KAFO)), crutches, canes, etc. c. transfers (on and off beds, chairs, toilets, in and out of cars)] d. dressing e. eating f. writing g. driving 6. Do they have any problems with skin care (decubitis ulcers)? 7. Do they have pain? 8. Are they taking any medications? Observations During Initial Interview: 1. Use of assistive devices? 2. Obvious indications of pain? 3. Do they continuously shift positions? 4. What is their affect? 5. What is their weight? Medical Aspects Notes 32 Common Functional Limitations: 1. Standing 2. Bending 3. Twisting 4. Lifting 5. Climbing 6. Stamina 9. Pain 10. Activities of daily living depending on extent of disability 11. Additional limitations caused by side effects of medication 12. Driving and driving a vehicle for long periods Vocational Impediment Connection: Depending on the functional limitation of the individual and the previous work history, vocational impediments vary. There is somewhat of a relationship between how far up on the spinal column the injury is and the level of impairment. If the disability is recent the counselor should assess the resulting limitations as they relate to the individual returning to former employment. If the disability has been evident for a long period of time, the counselor should assess how the impairment has prevented work or how it limits the types of jobs for which the individual is suited. Adaptations, abilities, and aptitudes should be considered as factors in the extent of impediment. Show how the injury has affected work, school, or other activities or will affect the individuals future job selection. Goal of Employment Considerations: Long-term vocational goals are generally applicable barring additional injuries such as traumatic brain injury. General health of the individual may be a factor, as well as, skin tolerance, stability of the spinal column, fit of the wheelchair, and endurance. Generally, L5, S1, S2: bowel and bladder functioning is good; sexual problems (obtaining and erection) could exist; transfers, eating, dressing, and personal hygiene is no problem; ambulation can be quite good Medical Aspects Notes 33 with a AFO. L1, L2, L3, L4: bowel and bladder problems; bipedal ambulation with a KAFO; transfers, eating, dressing, and personal hygiene are independent after training; use of hand controls to drive an automobile. T7 - T12: bowel and bladder problems; risk of respiratory infections due to cough muscles weakened; transfers, eating, dressing, and personal hygiene achieved through training; less bipedal ambulation using a KAFO; use of a wheelchair; hand controls for driving. T2 - T6: bowel and bladder problems; transfers, eating, dressing, and personal hygiene while achievable require much training; bipedal ambulation no longer practical; driving with hand controls and external trunk support; attendant care is not necessary but a roommate could be helpful. C7, C8, T1: bowel and bladder problems; hands and wrists are involved; training takes much longer and involves adaptive equipment; modifications to wheelchairs to make propulsion easier; velcro on clothing to make dressing easier; personal hygiene may require attendant care; modifications of bathrooms; eating with adaptive utensils; hand controls and steering wheel attachments for driving. C6: bowel and bladder problems; limited hand and wrist function; elbow range may diminish; may ambulate by a manual wheelchair but use of an electric chair; personal hygiene, transfers, and dressing provided by attendant care; individual is not likely to be able to live alone; driving is generally unlikely. C5: no wrist or hand movement; limited elbow movement; attendant care for personal hygiene, dressing, eating, and transfers; electric wheelchair. C2, C3, C4: most people with a C4 and those with C2 and C3 require ventilation to assist respiration; may have a permanent tracheostomy; able to use chin, mouth, or puff and sip control devices; may operate a wheelchair with a portable respirator; full time highly skilled attendant care. IPE Considerations: 1. Follow recommended treatment (e.g., bowel and bladder Medical Aspects Notes 34 elimination, skin care, respiration, etc.). 2. Consider diet and weight reduction. 3. Job site accommodations. 4. Training in the management of personal care attendants. 5. Job accommodations for attendant care. Medical Aspects Notes 35 SPINA BIFIDA Initial Interview Questions: 1. Does the individual have trouble with bowel and/or bladder control? Bladder infections? Does he/she use a catheter? 2. Does the individual have difficulty with activities of daily living, i.e., grooming, bathing, food preparation, eating, dressing, etc? 3. Does the individual require a personal care attendant? For what activities? 4. Does the individual have any home modifications? 5. Have the individual describe the following a. Loss of sensations. Where? Complete or partial? b. Loss of muscle functioning. Where? Complete or partial? c. Loss of muscle control (spasticity). Where? d. Muscle atrophy or weakness? Contracture? Where? e. Problems with skin breakdown or infection? Current status of skin condition? f. Chronic pain? h. Physical endurance 6. Have the individual describe types of assistive devices he/she utilizes, i.e., wheelchair, braces, crutches, etc. including situations in which they are used 7. What types of treatment has the individual has for this condition? (surgery, physical/occupational therapy, etc.) When? Where? 8. Has the individual has a recent diagnostic evaluation? Where? When? Name and type of physician? 9. Is the individual able to operate a vehicle? What modifications are necessary? 10. What type of support system do they have (especially at home)? 11. Does/has the individual utilized a shunt for cerebral spinal fluid drainage? 12. Does the individual have difficulty discriminating shapes, forms, numbers, letters, etc.? Medical Aspects Notes 36 13. Do they have difficulty with fine motor skills and dexterity? 14. Does the individual have difficulty with memory or cognition? Observations During Initial Interview: 1. Did the individual utilize assistive devices? What type? 2. Assess their ease of mobility. Have they adapted to assistive devices? 3. Did the counselor notice problems with speech clarity? Logical oral responses? 4. Did there appear to be signs of psychological difficulties? Problems with adjustment to their disability? 5. Were there signs of cognitive problems? Memory? 6. What was the individual's self-image? Work personality? 7. Did they exhibit proper grooming and hygiene? Common Functional Limitations: 1. Ambulation 2. Pushing 3. Pulling, pressing 4. Climbing 5. Standing 6. Stooping 7. Bending 8. Self-care (i.e., eating, food preparation, dressing, toileting, rolling over, grooming, hygiene, etc.) 9. Wheelchair independence (transfer, propelling wheelchair) 10. Control of bowel and/or bladder Medical Aspects Notes 37 11. Writing 12. Vehicle operation 13. Range of motion in extremities 14. Muscle control 15. Reflex control 16. Motor coordination 17. Grasping 18. Handling 19. Eye/hand/foot coordination 20. Hand/finger dexterity 21. Kneeling 22. Crawling 23. Crouching 24. Lifting 25. Carrying 26. Reaching 27. Self-image 28. Preoccupation with limitations (adjustment to disability) 29. Self-confidence Vocational Impediment Connection: Look at the specific functional limitations and show how those inhibit the individual’s ability to get a job or limits their future job selection. If the condition is severe the individual in most cases will have multiple functional limitations that can easily be related to vocational problems. The individual may have secondary conditions which cause vocational limitations and also may be unable to operate motor vehicles. Medical Aspects Notes 38 Goal of Employment Considerations: The counselor should explore the extent of functional limitations caused by the disability but must be sure to go beyond that and explore all limitations that would impact their ability to get or keep a job. The individual may have secondary conditions, e.g., hydrocephalus and have limitations resulting from it. Also, the counselor should consider potential barriers such as the inability to operate a motor vehicle or use public transportation, etc. IPE Considerations: 1. Healthy activity levels and exercising are critical to individuals with spina bifida's proper body maintenance. Not only is this essential to the individual's mental health, it becomes important to primary body functions such as: circulation, bowel management, skin care, range of motion and weight control. The counselor should become familiar with community resources, advocacy self-help groups, peer support and recreational facilities which are accessible. The counselor should then refer them to these groups, facilities, etc. 2. Individuals with the above conditions should be referred to a physiatrist if multiple areas of range of motion or paralysis is involved. Often times the physiatrist will be able to work with physical and occupational therapists to assist them in prescribing exercises, strengthening muscles and adaptive equipment. 3. The psychological and financial effects of the disability is sometime overwhelming. The counselor should strive to be supportive, understanding and positive with this population. Consider referring the individual to a psychotherapist and/or support groups if indications warrant it. 4. Recent technological advances in rehabilitation have dramatically changed many individuals with severe physical disabilities' vocational and independent living prospects. Advances in electronic, remote control, communications, etc. have opened many doors for individuals with spina bifida. The counselor should become knowledgeable about these systems, trying to integrate them into the individualized program Medical Aspects Notes 39 MOTOR NEURON DISEASES Amyotrophic Lateral Sclerosis; Progressive Spinal Muscular Atrophy; Progressive Bulbar Palsy; Werding-Hoffman Disease; Charco-Marie-Tooth Disease; Others. This is a group of disorders characterized by muscular weakness and wasting due to progressive degeneration of neurons and anterior horn cells in the upper spinal cord. These disorders have no known cause. Initial Interview Questions: 1. Does the individual have trouble breathing or having any respiratory infections? 2. Does the individual have trouble with bowel and/or bladder control or have any bladder infections? 3. Does the individual require a personal care attendant and, if so, for what activities? 4. Does the individual have a loss of sensation and, if so, where? 5. Does the individual have a loss of muscle functioning and where? 6. Does the individual experience spasticity and where? 7. Does the individual have any muscle atrophy or weakness and where? 8. Does the individual experience any problems with skin breakdown or infection? 9. Is the individual in pain? 10. Does the individual use assistive devices and, if so, describe? 11. Does the individual have speech difficulties? 12. Does the individual tire easily? 13. Does the individual have difficulties with balance and/or motor coordination? 14. Does the individual have trouble swallowing or do they choke Medical Aspects Notes 40 frequently? 15. Is the individual able to operate a motor vehicle and, if so, what modifications are necessary? Common Functional Limitations: The course of these diseases is progressive, with increasing functional limitation over time. The functional limitations listed below are in order of emergence from early to late. 1. upper extremity mobility 2. strength 3. Whole body mobility 4. self-care 5. speech Vocational Impediment Connection: Since these disorders typically onset after the age of forty, most persons are either competitively employed or engaged in homemaking. The initial symptoms involve weakness and reduced coordination and dexterity in the hands and feet. Whether these symptoms produce a vocational impediment at this point depends primarily the requirements of the person's employment. Persons employed in some agriculture, industrial, clerical, and homemaking occupations may encounter vocational problems very early in the course of the disease. Persons in some professional, technical, managerial, and sales occupations are most likely to encounter difficulties in self-care and activities of daily living. Since these conditions cannot be treated, however, one can expect the latter group to encounter some vocational problems in their future. Goal of Employment Considerations: Since most persons are either employed or engaged in homemaking at the time of onset, the basic vocational rehabilitation strategy is one of maintaining current employment. This strategy is most readily achieved using rehabilitation engineering, job modification, and restructuring, and assistive devices. Current employment in some professional, technical, managerial, clerical, sales, and homemaking occupation is a positive indicator of successful rehabilitation because cognitive functioning remains intact and physical demands can be altered Medical Aspects Notes 41 with rehabilitation engineering approaches. Retention of employment in some agricultural and industrial occupations is more problematic because of the motor requirements involved. A thorough job and task analysis of current employment will usually disclose the extent to which rehabilitation engineering approaches can be applied. Close work with the employer will also indicate whether transfer into other jobs within the firm is possible or with or without some type of training. Although it is tempting to consider the rate of progress of the disease as a major factor in determining the goal of employment, this is pointless in everyday practice. There is no way to meaningfully estimate this in the individual case, particularly when the person comes to vocational rehabilitation early in the course of the disease. IPE Considerations: 1. The person with a motor neuron disease has a serious, sometimes fatal disorder. Coping with this is a major issue both for the person and family members. At a minimum, referral and involvement with a support group should be considered. Referral for mental health counseling may also be considered. A person might be monitored for signs of depression and suicidal thoughts. 2. Clear and explicit plans for post-employment services should be developed at the time the initial vocational rehabilitation case is closed. Additional services will be typically required as the person's physical functioning deteriorates. 3. First thought should be given to maintaining current employment. 4. Consider rehabilitation engineering to include job and worksite modifications. Medical Aspects Notes 42 POST-POLIO SYNDROME Initial Interview Questions: 1. Do they experience fatigue (i.e., either muscle fatigue or general body fatigue)? 2. Do they have any bone and/or joint problems? 3. Do they experience weakness in muscle, both those originally affected and those unaffected? 4. Have they experienced recurrent hospital admissions for low back pain or muscle spasms? 5. Have they experienced and increase in pain (especially areas that carry weight, i.e., knees, ankles, feet, hips)? 6. Have they been plagued with a cold lasting more than one month and a persistent cough that prescribed medication does not seem to relieve? 7. Do they have periods of shortness of breath? 8. Have they had to curtail work loads? 9. How have they coped in the past with residuals of polio and how are they coping now? 10. Do they use assistive devices? Are they adequate? 11. Are they experiencing any psychological effects because of returning symptoms of the disease? Observations During Initial Interview: 1. Are they using assistive devices? 2. Do they need to rest after speaking one or two sentences? 3. how is their speech clarity? 4. Is there any depression or anxiety noticeably present? Common Functional Limitations: 1. Pain in muscles or joints 2. Sleep problems Medical Aspects Notes 43 3. Breathing difficulties 4. Swallowing problems 5. Fatigue 6. Lifting, reaching, walking, climbing, balancing, stooping, kneeling, crouching, twisting, fingering, motor coordination, eye-hand-foot coordination 7. Self care including: eating, hygiene, dressing, grooming 8. Stamina and strength Vocational Impediment Connection: Consider that transportation may be a barrier if the mode of transportation is no longer accessible. Depression may interfere with working or preparing to work because of recurrence or exacerbation of limitations. Often individuals have worked for years, but now no longer can perform necessary duties. Vocational problems may relate to activities of daily living in that being unable to care for themselves at home affects ability to get to or perform work. Goal of Employment Considerations: The counselor needs to be informed on adaptations that might be possible either to help the client remain in their present job or to prepare for a new one. These can be anything from being refitted for a brace to assessment of a wheelchair. For those who use a wheelchair, it might be advisable to have it motorized. Some clients might need ventilators for night use. IPE Considerations: 1. Be aware that the individual may require rest during a work day, flexible work hours or part time work. This should be a consideration when arriving at the job goal or in placement. 2. Independent living services may be necessary to enable the individual to be able to work outside the home. These might be designed for the purpose of getting out of the home (a ramp) or to simplify work in the home thus storing strength for outside pursuits. 3. Consideration should be given to possible communication devices as required. Medical Aspects Notes 44 4. Consideration should be given to mobility or transportation aids or devices a required. 5. Consideration of supportive counseling as the psychological effects of post polio are sometimes overwhelming for individuals 6. Follow medical advice, e.g., rest, exercise, diet. Medical Aspects Notes 45 AUDITORY Normal Structure Outer ear oval window auricle inner ear external ear labyrinth canal auditory system cerumen vestibular system mastoid process eighth cranial nerve middle ear acoustic/auditory nerve tympanic cavity cochlear nerve branch tympanic membrane vestibular nerve branch eustachian tube vestibule (chamber) ossicles cochlea malleus semicircular canals incus organ of Corti stapes Disorders hearing impairments: Outer ear conditions conductive Middle ear conditions: sensorineural perforated tympanic membrane mixed otitis media Categories mastoiditis prelingual Inner ear conditions: prevocational labyrinthitis postvocational vertigo congenital Meniere's disease acquired tinnitus presbycusis ototoxic agents recruitment Diagnostic identification hertz (pitch) 125 to 8,000 children: adults 500 to 2,000 unresponsiveness bone conduction behavior problems audiometry adults: impedance: irritable audiometry hostile acoustic hypersensitive reflex tympanmetry tuning forks speech audiometry audiometer speech reception threshold audiology speech discrimination pure tone audiogram caloric test decibles (loudness)-10 to 110 nystagmus electro-nystagmography Medical Aspects Notes 46 Treatment otolaryngologist behind-the-ear audiologist eyeglass model speech and language therapists telecoil auditory training T switch surgery: alerting devices myringotomy telephone aids (TDD) needle aspiration assistive listening devices: mastoid-ectomy hard-wire group access tympanoplasty lip-reading myringoplasty sign language: stapedectomy American Sign Language (ALS) cochlear implant Signed English vibrotactile aids simultaneous Hearing Aids: communication canal type finger-spelling in-the ear PsychoSocial age of onset grief daily communication denial adult onset anxiety withdrawal frustration aggression depression dominating deaf community vulnerability Life Style interpreters small talk loss of privacy recreation independence Vocational stereotypes devices may be sensitive to assistive devices extremes in temperature visual cues Medical Aspects Notes 47 HEARING IMPAIRMENTS Initial Interview Questions: Some of the questions in this section would be appropriate for people with hard of hearing impairments but not for people totally hearing impaired. 1. Have them describe difficulties with hearing (i.e., discriminating pitches, decibel levels, speech discriminations, intelligibility of sounds, etc.). 2. Has the individual had trouble with balance or coordination? 3. Do they experience ringing in their ears or "head noises." 4. Do they take medications? Name and function of the medications. Who prescribed them? When prescribed? What are the side effects? 5. Does the individual have a history of ear infections? 6. Has the individual had recent otological and/or audiometric examinations? When? With whom? 7. Are both ears involved? 8. Has the individual ever used a hearing aid? How often is it used? 9. If they use an aid, what type? Age of the aid? Is it adequate and corrective? 10. Do they read lips? Use sign language? Use an interpreter? 11. Has the individual ever had speech therapy? Observations During Initial Interview: 1. Are they wearing hearing aids? 2. Did they have difficulty understanding you? Did they rely on facial cues? 3. Does the individual use speech for expressive communication, and if so do they exhibit abnormal speech patterns? 4. If the individual signs, what type of sign language is used Medical Aspects Notes 48 (ASL, English, etc.)? 5. Were there signs of psychological problems and/or chemical dependency? 6. Are there other observable disabilities? Common Functional Limitations: 1. Discriminating sounds (i.e., frequencies, decibel levels, speech discrimination)> 2. Understanding instructions. 3. Communicating with peers. 4. Speech clarity. 5. Intelligibility/context meaning of sounds. 6. Balance/motor coordination 7. Self-image 8. Deficits in school achievement 9. Problems in conceptualization. Tendency to take things in very concrete ways. 10. Society tend to overestimate the social skills and maturity of some individuals with severe hearing impairments because it is a hidden disability, and because there is little knowledge in the general population about cultural deficiencies experience by people with total hearing impairments. 11. Potential barriers from other disabilities (e.g., mental illness, developmental disabilities, alcoholism, cerebral palsy, etc.). Vocational Impediment Connection: Making a connection between loss of hearing and vocational problems is not difficult. An individual with moderate to severe hearing loss has obvious work related functional limitations. These limitations relate to almost any job they might enter because of communication difficulties. It may be more difficult to show a vocational impediment with individuals with mild hearing losses. Specifically address Medical Aspects Notes 49 the functional limitations of the individual, and show how they have caused them difficulty in past jobs or how they will cause them difficulty in future jobs. Goal of Employment Considerations: 1. It is important to know if the individual has had special education/training in sign language or if they have attended a specialized institution for people without hearing (such as a School for the Deaf). It is relevant to learn who they functioned while at school, especially in a residential setting. 2. Psychological testing and vocational assessment for people with hearing impairments present a great challenge to the evaluator. The counselor should always refer them to an evaluator who is particularly skilled in areas of manual communication and working with hearing impairments. 3. Underestimating the potential of a person without hearing or hearing impaired is much more prevalent than overestimating their vocational intelligence, aptitude, and achievement levels. The counselor should realize this and strive for cultivation of their strengths. Intelligence testing results are often not indicative of their true level of functioning. 4. The counselor should be aware of individuals whose hearing impairment occurred later in life. It may be that in some cases those having severe hearing impairments introduced by trauma, have a more difficult time with adjustment to their disability. 5. The nature of the disability may involve isolation, segregation, and loneliness for the person, especially later in life. In some cases psychological disturbances and/or chemical dependency accompany the disability. If this is the case, the individual should be referred to a therapist trained in manual communication. IPE Considerations: 1. Consider life experience adjustment counseling or training. Some people with hearing impairments lack life experiences and need adjustment counseling to learn more about the real world, and how they might negotiate it to be successful. 2. Assure proper fitting of any hearing aids used. 3. Assess the need for and make arrangements for necessary Medical Aspects Notes 50 assistive devices (e.g., speech aids, warning aids, communication devices, TTY, etc.). 4. Assess the need for training in speech reading and signing, and provide necessary training. 5. Consider using interpreters throughout the rehabilitation process as needed. 6. Carefully assess the degree of hearing loss and the individual's communication skills when arriving at vocational goals. Include in the assessment their lip reading abilities, sign skills, and any communication devices that may be possible. 7. Provide community awareness so that the individual is acquainted with services available to them. Medical Aspects Notes 51 VISUAL SYSTEM Normal Structure lacrimal glands accommodation conjunctiva vitreous space cornea vitreous humor sclera retina choroid coat rods and cones iris rhodopsin anterior chamber adaptation aqueous humor fovea ciliary process optic nerve canal of Schlemm optic disc intraocular pressure binocular vision ciliary muscle Disorders visual acuity blindness ophthalmologist visual impairments conjunctivitis central field of vision gonococcal conjunctivitis night vision trachoma binocular vision: keratitis diplopia glaucoma: amblyopia chronic legal blindness: 20/200 or worse in open-angle the better eye with correcting acute closed angle lenses cataracts OR retinopathy central field of vision limited arterio-sclerotic retinopathy to an angle of 20 degrees or less diabetic retinopathy refractive errors proliferative retinopathy myopia detached retina hyperopia retinitis pigmentosa astigmatism macular degeneration presbyopia nystagmus injuries to the eye: strabismus scratches supression foreign bodies amblyopia chemical burns Diagnostic testing visual acuity 20/200 gonioscopy visual field ophthalmoscopic examination perimeter ophthalmoscope peripheral vision slit lamp central vision flourescein angiography tonometry Medical Aspects Notes 52 Treatment eyeglasses intracapsular cataract extraction ophthalmologist virectomy optometrist corneal transplant (keratoplasty) optician low-vision optical aids antibiotics magnifiers miotics telescopes surgery: telemicroscope photocoagulation television iridotomy computers filtration surgery voice synthesizers scleral buckling mobility aids cataract surgery guide dogs extra-capsular cataract extraction prescription canes intraocular lens insertion orientation and mobility training PsychoSocial age of onset denial grief stereotyping loss nonverbal communication despair Life Style partially opened doors daily living skills Vocational impact of visual disorder nature of employment transportation Medical Aspects Notes 53 VISUAL IMPAIRMENTS Initial Interview Questions: 1. What is the specific cause of the visual impairment? 2. How long have they had the visual impairment? (In some cases one might expect better emotional adjustment the longer they have had the visual impairment. On the other hand, the longer they have had sight, might increase their chances of comprehending and being oriented to the visual world). 3. Is their remaining vision constant (e.g., diabetic retinopathy, frequently causes variations in acuity)? 4. Does the individual have blurring of vision or double vision? 5. Does the individual have a driver's license and is it restricted? Observations During Initial Interview: 1. Was the individual wearing glasses? 2. Does the individual have any obvious signs of eye abnormality (e.g., discoloration or abnormal eye movement, etc.)? 3. Did they exhibit difficulty in reading materials or signing forms? 4. Did they need assistance in mobility (e.g., use of a cane, guide dog, or a sighted aide, etc.)? Common Functional Limitations: 1. Reading 2. Writing 3. Walking 4. Space perception 5. Form perception 6. Color discrimination Medical Aspects Notes 54 7. Field of vision deficit 8. Night vision deficit Vocational Impediment Connection: An inability to distinguish sizes, shapes, distances, motion, or colors would cause very obvious vocational impediments. Limited visual acuity, depth perception or field of vision can limit the individual's job alternatives. The individual may also have problems with transportation, if the have an inability to drive. The may also have difficulties in many jobs because of inabilities to read. Some visual impairments may rule out night jobs because of the inability to see in the dark. Goal of Employment Considerations: Individuals with visual impairments should be considered as potential referrals to the agency, commission, or bureau which specifically serves people without sight and those visually impaired. The more severe the visual impairment, the more obvious such a referral becomes because of the expertise that can be provided through those organizations. A person with a visual impairment's goal of employment would rest upon the individual's functioning abilities regardless of the amount of the loss of their sight. A great abundance of training and technological aids are available for the purpose of overcoming barriers caused by the loss of sight. IPE Considerations: 1. Counseling should be considered for those having difficulties in adjusting to the loss of sight. 2. Technological aids should be considered for the purpose of making the best use of a person's remaining sight or for the purpose of overcoming inabilities to see. Examples would range from light sensors to such items as optacons, which allow people with visual impairments to read print. 3. Necessary training might be considered in the areas of mobility, braille, etc. 4. Job site modification might be needed. Medical Aspects Notes 55 BLOOD AND THE IMMUNE SYSTEM Normal Structure blood: lymphatic system *carries oxygen and nutrients lymph nodes *facilitates communication for spleen endocrine system thymus *carries wastes for elimination bone marrow *protects the body leukocytes *promotes clotting granulocytes *helps regulate temperature neutrophils hemapoiesis basophils hematopoiesis eosinophils erythrocytes agranulocytes: leukocytes lymphocytes: thrombocytes (clotting cells) B lymphocytes leukocytosis T lymphocytes thrombocytopenia memory cells thrombocytosis helper cells plasma suppressor cells erythrocytes: (antigen, antibodies, allogens) hemoglobin (iron) humoral immunity vitamin B12 monocytes: folic acid macrophages (phagocytosis) reticulocytes acquired immunity Leukocytes & Immunity: hemostatsis (clotting process) nonspecific or innate immunity platelets inflammatory response clotting factors I to XII phagocytes Disorders Blood dyscrasias Thalassemia (Cooley's Anemia, anemia Mediterranean Anemia) normcytic polycythemia vera normochromic agranulocytosis (neurtropenia) macrocytic purpura microcytic leukemia hypochronic hemophilia aplastic anemia (pancytopenia) hemophilia A (classic; Factor VII) hemolysis hemophilia B (Christmas; Factor IX) splenomegaly von Willebrand's disease (Factor iron deficiency (anemia) VIII) pernicious anemia hemoarthrosis intrinsic factor Sickle Cell Anemia: pallor hemoglobin S dyspnea necrosis tachycardia cardiomegaly Medical Aspects Notes 56 Disorders con't exertional *unexplained persistent cough dyspnea *drenching night sweats sickle cell crisis *severe fatigue unrelated to sickle cell trait exercise HIV stress or drug use AIDS *persistent diarrhea opportunistic diseases & infections *swollen lymph nodes pneumocystis (lymphadenopathy) carnii HIV>ARC>AIDS candidiasis Group I acute infection, Kaposi's sarcoma flulike symptoms AIDS dementia complex Group II asymptomatic infection *weight loss Group III persistent (3 mo) *loss of appetite lymphadenopathy Group IV weight loss, Opportunistic infection, Neuropathology, secondary, Cancers—Kaposi’s sarcoma Diagnostic standard blood tests: hemocrit (proportion of red complete blood count cells in plasma) red blood cells per cubic ml other counts: white blood cells per cubic ml reticulocyte differential platelet (proportion of mean corpuscular volume (MCV) neutrophils mean corpuscular hemoglobin esoinophils concentration basophils bleeding time lymphocytes prothrombin tim (PT, ProTime) monocytes) partial prothombin time (PTT) per 100 white blood cells bone marrow aspiration hemoglobin per 100 ml ELISA & Western Blot Treatment general: transfusions venesection (phlebotomy HIV/AIDS: transfusion zidovudine (Retrovir) hemophilia Azidothymidine (AZT) plasma or plasma concentrates supportive care sickle cell anemia: prevention of opportunistic nutrition infections PsychoSocial hidden disability stress/anxiety denial stigma frequent illness fear (innocent victims) unpredictability guilt hopelessness self-blame depression fear of abandonment fear of death illness is "deserved" Medical Aspects Notes 57 anxiety ostracism HIV: unpredictability discrimination Life Style fatigue balance of rest & activity daily schedules sexual function not a problem moderate exercise HIV - transmission of disease Vocational remove toxic substances avoid joint damage frequent rest periods attitudinal barriers avoid extreme temperatures Medical Aspects Notes 58 HEMOPHILIA Initial Interview Questions: 1. How frequently do they bleed? 2. How severe is the bleeding? 3. What is the longest time of incapacitation? 4. Do they have any other blood related problems (e.g., hepatitis, HIV)? 5. Are there any restrictions in movement? 6. Are there any restrictions terms of activities? Observations During Initial Interview? 1. Are there any problems with gait? 2. Can they sit or stand for long periods? 3. Do they appear to be in pain or general discomfort? 4. Are there restrictions in motion/movement? Common Functional Limitations: 1. Walking 2. Climbing 3. Stooping, kneeling, crouching 4. Lifting 5. Strength 6. Working in physically hazardous situations 7. Limited range of motion 8. Chronic pain 9. Fear of injury which might cause bleeding Vocational Impediment Connection: Medical Aspects Notes 59 Individuals with hemophilia should obviously avoid job situations which have physical risks for injury and this a major vocational impediment. Also, because people with hemophilia often miss school or are treated in ways which may not demand full academic achievement, school achievement must be carefully assessed both in terms of school records and also achievement testing. In many cases there may be limited academic skills. The counselor should assess their amount of experiences in terms of vocational and life experiences as they often have little or none from which to draw. A work history is often not present for individuals in transition from school to work, so they lack work skills, and an understanding of the expectations of the workplace. Goal of Employment Considerations: Consider assessing the severity of the disorder, the orthopedic results in terms of joint immobility and the response of the individual and the family in terms of long-term adjustment to the conditions of the disability. The individual might be assessed as to their willingness to follow a medically appropriate treatment regime to maintain functional states and have parental or environmental support and encouragement. In terms of specific treatment the individual must be active without taking potentially harmful risks, must have an adequate supply of blood coagulant factor, and be under medical supervision (usually both medical and orthopedic). In the case of joint pain, which is secondary to the primary condition of hemophilia, analgesics and anti-inflammatory drugs are often used. Aspiring must not be used as it interferes with coagulation. IPE Considerations: Physical demands of the jobs must be assessed before a vocational plan can be developed. Usually the jobs need to be sedentary or light work. They should avoid hazardous work and in many cases seek a job requiring limited joint activity. 1. Avoid job goal and working environments where bumping and/or cutting themselves is a risk. 2. Consider jobs of sedentary or light duties vs. moderate to heavy work. 3. Follow medical recommendations concerning proper use of clotting agents. Medical Aspects Notes 60 SICKLE CELL ANEMIA Initial Interview Questions: 1. Have the individual describe their history of illness or infections. 2. How often have they entered a sickle cell crisis? Have them describe the crisis. 3. Is the individual involved in any treatment or therapy and what is their medication regime? 4. Has the individual lost excessive time from school and/or work due to illness? 5. Explore the individual's strength and stamina level. Observations During Initial Interview: 1. Does the individual appear to be lacking in strength or stamina? 2. Is there a noticeable shortness of breath? 3. Do they appear to be in pain? Common Functional Limitations: 1. Dependability (this may be reduced because of periodic episodes of sickle cell crisis)> 2. Frequent changes (frequent changes of duties can cause stress which can exacerbate the problem)> 3. Strength 4. Stamina 5. Working in the cold or heat 6. Working in wet, humid conditions 8. Pain (e.g., abdominal, back, joints) 9. Joint stiffness and swelling Vocational Impediment Connection: Medical Aspects Notes 61 The functional limitations indicated earlier need to be related to the individual's ability to obtain or maintain employment. There are basically three things to consider here. First of all, how do the periodic crises affect the abilities to work? These crises cause some functional limitations that have been indicated earlier along with nausea, vomiting, pain, open sores, abdominal pain, shortness of breath, and aching joints. Secondly, you will need to assess any limitations that have been caused from other organs affected by the disease. Third, you need to consider the difficulty in being hired given the potential time away from work due to periodic crises. Goal of Employment Considerations: In adults mortality of people with sickle cell anemia is commonly due to infection or renal failure. There is no peak mortality period in adulthood as there is in childhood. The overall lifespan of adults has not been defined. The disease is unpredictable. Consider vocations for the remaining functional abilities of the individual. IPE Considerations: 1. Vocational goals should be chosen with the specific functional limitations in mind (e.g., avoiding heat, cold, rapid temperature changes, excessive humidity, and stress). 2. Strength and stamina may be affected. Those may need to be built up prior to eventual placement or considered in the type of job sought. 3. Preparation for placement should take into account that perspective employers may not look with favor on hiring individuals who may need to miss work from time to time for treatment. 4. Pain management may be needed in some cases. Medical Aspects Notes 62 HIV (AIDS) Initial Interview Questions: 1. What does the individual know about HIV disease? What are their current symptoms? What are the changes in their functions (i.e., eating, sleeping, physical activity level)? 2. What are their HIV related illness, if any? 3. Is the applicant involved in medical treatment, (e.g., scheduled clinic appointments)? How often do they attend and are they keeping all appointments? 4. If currently receiving medical services, what is the treatment plan? How does the individual feel about the medical treatment plan and provider? 5. Have there been any hospitalizations? If so, how many and for what? 6. What have physician told the individual regarding their medical condition and what is their understanding and responsibility in maintaining a healthy life? 7. Is medication being taken? Does the individual have the resources to obtain the necessary medication? Are there any side effects from the medication? 8. Does the individual understand the importance of their medications and do they adhere to the regime required? Are the medications or treatments affecting their ability to work? 9. When was the last episode of an illness where normal activity was interrupted? What has been the recuperation time between illnesses? What are the individual's preventive measures to ward off future illnesses? Observations During Initial Interview: 1. Do you see evidence of fatigue? 2. Does the applicant appear underweight? 3. did you notice any problems breathing? 4. Do you notice any short term or long term memory deficits? Common Functional Limitations: Medical Aspects Notes 63 1. Cooperation 2. Dependability 3. Decision making 4. Frequent change 5. Stamina 6. Strength 7. Temperature change 8. Depression 9. Fear 10. Isolation Vocational Impediment Connection: Consider how the symptoms of the disease have affected the applicant's ability to get or keep reasonable employment. They may have lost previous employment directly because of specific limitations they have. Think in terms of how this disability and the resulting limitations will cause them difficulties being able to obtain a job or maintain it. An example might be that they fatigue easily which would limit the types of jobs they could do and may also limit the number of hours they can work. Employer prejudice may also play a role. Goal of Employment Considerations: Consider each case individually. In general, individuals with the diagnosis of AIDS vs HIV do not have a favorable prognosis for having a significantly long work life. Individuals who have a diagnosis of Aids Related Complex (ARC) usually have an uncertain prognosis and many have the potential for a significantly long work life. IPE Considerations: 1. Assure that the client has adequate support. This might include family, significant others, a therapist, a support group, spiritual support, doctors, social workers etc.. With this type of support, their chances of successful involvement in rehabilitation significantly increases. Medical Aspects Notes 64 2. Assure that the client has stable living arrangements. 3. Determine the client's best working time (e.g., morning, afternoon, evening, part-time, full time, etc.). 4. Consider the potential need for mental health counseling or adjustment counseling. 5. In determining a vocational goal, be sure to consider the medical needs and potential health insurance needs of clients. 6. Extensive job-seeking-skills training might be considered. In the area of job-seeking-skills training, it is important to provide information to the client on how to handle explanations of their disease with potential employers and co-workers. 7. Since under certain conditions (accidents in health care - mostly percutaneous injury- blood transfusions, sexual intercourse, mother to fetus, intravenous needle sharing, and possibly breast milk) this is an infectious disease, consider in some cases the possible transmission of the disease when choosing a vocational goal. 8. Confidentiality is a complex issues with this disease and should be carefully explored. Medical Aspects Notes 65 ENDOCRINE DISORDERS Normal Structure thyroid anterior lobe thryoxine (metabolism) thyroid stimulating hormone parathyroid posterior lobe parathyroid hormone hypothalamus andrenal glands antidiuretic hormone epinephrine islets of Langerhans norepinephrine insulin adrenal cortex glucagon steriods testes pituitary gland ovaries Disorders Hyper thyroidism glycouria (Grave's disease polyuria Thyrotoxicosis polydipsia Exophthalmic Goiter) insulin-dependent (Type I) Hypothyroidism non-insulin dependent (Type 2) (Myx edema) polyphagia Cushing's Syndrome ketones (Adrenal Cortex Hyperfunction) ketoacidosis Buffalo Hump diabetic coma Addison's Disease insulin shock (Adrenocoritcal Insufficiency hypoglycemic agents Diabetes Insipidus myocardial infarction Diabetes mellitus cerebral vascular accident pancreatitis retinopathy gestational diabetes peripheral neuropathy hyperglycemia Diagnostic Blood Tests Blood Tests Diabetes - Serum thyroxine (T3 & T4, TSH) fasting blood sugar (FBS) Radioiodine Uptake Test (131I) postrandial blood sugar glucose tolerance test Treatment Hyperthyroidism (Grave's disease, Thyrotoxicosis, Addison's Disease Exophthalmic Goiter) Adrenocortical Insufficiency antithyroid iodine 131 sythetic corticosteroids subtotal thryoidectomy Diabetes Insipidus Hypothyroidism hormonal preparations Myxedema Diabetes Mellitus synthroid control of glucose Cushing's Syndrome insulin (Adrenal Cortex Hyperfunction) glucometer corticoosteriod reduction diet Medical Aspects Notes 66 PsychoSocial Emotional outbursts hidden disability irritability fear of complications anxiety family support body image relating through food & alcohol Life Style medication diet Vocational schedules emotional stress minor cuts and scratches Medical Aspects Notes 67 ENDOCRINE DISORDERS Initial Interview Questions: 1. Have the individual describe the onset and history of the problem. 2. Have the individual explain/describe the following: a. Method of control, i.e., pills, injections, diet? b. Amount of medication? (insulin units) c. When taken? d. Problems with control? Give recent example and dates. 3. Does the individual have difficulty with any of the following? If so, describe: a. Vision? Do they wear glasses or contacts? b. Urination? Bladder and/or kidney infections? c. Hypertension? d. Circulation? Leg pains or numbness? e. Tingling or loss of sensation in extremities? f. Excessive vomiting or diarrhea? g. Dizziness or fainting spells? h. Becoming easily fatigued? i. Concentration? j. Emotional swings? k. Healing of cuts or skin conditions? 4. Does the individual follow an established routine of diet, exercise, rest and sleep? Describe. 5. Have the individual discuss any activities and/or environmental conditions which causes him/her fatigue or complications. Observations During Initial Interview: 1. Did the individual exhibit problems with ambulation? 2. Did the individual seem in obvious pain? Complain of pain in extremities? (especially legs and feet) 3. Was the individual overweight? 4. Did the individual seem to be alert? Logical oral responses? What was his/her energy level? Common Functional Limitations: Medical Aspects Notes 68 1. Physical stamina/endurance 2. Standing 3. Walking 4. Motor coordination 5. Heavy exertion 6. Tactile discrimination 7. Finger dexterity 8. Handling 9. Grasping 10. Manual dexterity 11. Tolerance to extremes in temperature 12. Tolerance to long hours without rest/food intake 13. Tolerance to occupations that pose unusual injury hazards (i.e., cuts, burns, skin injuries, etc.) 14. Concentration 15. Visual acuity Vocational Impediment Connections: Often the problems related to the disability will affect the individuals stamina. Emotional aspects of the disability may be revealed in an inconsistent work history. Also with the onset of the disease they will need rest during the work day, and regular meal times. Goal of Employment Considerations: It is important to ascertain the amount of control the individual has over the disease, e.g., do they adhere to diet, self-care schedules, care of feet, syringe utilization, sleep, and proper usage of medications. What is the prognosis of complicating factors such as visual problems, amputations, or Medical Aspects Notes 69 kidney problems. IPE Considerations: 1. Maintain the medical control through diet, medications, etc. 2. Maintain weight control. 3. Avoid jobs with irregular hours, long hours of work without breaks, and irregular physical exertion. 4. In the discussion of job goals, place some considerations on potential long term complications, e.g., visual problems, amputations, kidney problems. Medical Aspects Notes 70 MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS Normal Structure periosteum movement hematopoiesis circumduction (circular) humerus eversion (turned outward) femur inversion (turned inward) carpals flexion (bending tarsals extension (straightening) mandible abduction (away from midline) connective tissue adduction (toward midline) ligaments ulnar deviation (hand away) tendons radial deviation (hand inward) cartilage pronation (body downward) fibrocartilage supination (body upward) elastic cartilage dorsiflexion (backward) vertebrae ball and socket cervical hinge thoracic gliding lumbar pivotal sacrum muscles coccyx involuntary intervertebral disks smooth annulus striated or skeletal nucleus muscle sheath pulposus origin joint insertion articulation flexors fibrous or fixed extensor pubis symphysis cartilaginous synovial joints bursa articular cartilage Disorders rheumaoid arthritis uric acid autoimmune response purines pannus ankylosing spondylitis ankylosis kyphosis osteoporosis remissions secondary osteoporosis exacerbations fractures systemic lupus erythematosus Colle's crush compression osteoarthritis osteomyelitis (degenerative joint disease) fractures - compound or open gout bursitis olecranon certified prosthetist suprapatellar tendinitis pylon Medical Aspects Notes 71 tendosynovitis edema carpal tunnel syndrome SACH herniated disc terminal device (herniated nucleus pulposus) Complications nucleus pulpus annulus contractures low back pain scoliosis static pain phantom sensation kinetic pain phantom limb pain sciatica neuromas lordosis puncture and penetration spondyloysis Amputation spondylolisthesis traumatic scoliosis distal Fractures forequarter or interscapular- closed or simple thoracic transverse shoulder disarticulation (S/D) oblique above the elbow (A/E) spiral elbow disarticulation (E/D) complete below elbow (B/E) incomplete or partial wrist disarticulation (W/D) impacted partial hand comminuted hemipelvectomy displaced hindquarter complicated hip disarticulation (H/D) compression chronic pain syndrome pathologic Colle's stress - open or compound closed reduction open reduction dislocation subluxation Tissue injuries contusion ecchymosis hematoma strain sprain laceration above the knee (A/K) knee disarticulation (K/D) below the knee (B/K) Syme's transmetatarsal partial foot prosthesis orthopedic surgeon Medical Aspects Notes 72 Diagnostic x-ray blood tests arthrogram erythrocyte discography sedimentation rate myelography C-reactive protein arthroscopy rheumatoid factor arthocentesis (latex fixation or agglutination bone scan (radioisotopes) test) magnetic resonance imaging (MRI) LE prep CAT scan antinuclear antibodies (ANA) Treatment Physical therapy antidepressant passive physical therapy active transcutaneous electrical nerve atrophy stimulation (TENS) diathermy stress management casts biofeedback pica electromyogram assistive devices acupuncture orthosis meditation orthotist hypnosis Taylor Jewett Hyperextension progressive relaxation training TLSO operant conditioning Knight Chairback Traction nerve blocks continuous neurosurgical procedures intermittent sympathectomy skeletal neurectomy Kirschner wires rhizotomy Steinmann pins chordotomy Crutchfield tongs rheumatoid arthritis Surgery salicylates open reduction gold compounds internal fixatino pruritis arthroplasty proteinuria arthrodesis penicillin synovectomey immuno-supressant laminectomy systemic lupus erthematosus spinal fusion salicylates carpal tunnel repair steroids medications osteoarthritis salicylates gout tophi nonsteroidal anti-inflammatory drugs ankylosing spondylitis (NSAIDS) nonsteroidal anti-inflammatory corticosteroids osteoporosis pain treatment vitamin D muscle relaxants osteomyelitis analegsics antibiotics Medical Aspects Notes 73 PsychoSocial dependence litigation uncertainty benefits powerlessness body image anger grieving loss hostility family support depression miracle cures pain Life Style organization hygiene diet exercise Vocational see handout Medical Aspects Notes 74 FRACTURES (DELAYED UNION, NON-UNION, AND MALUNION) Initial Interview Questions: 1. What has their physician told then about their prognosis? 2. Do they have any problems with weight bearing? 3. Are there any known complications? Infections? 4. Is there loss of feeling? Strength? Any problems lifting? 5. Are there difficulties with range of motion? Describe. 7. Have x-rays been taken? Where can medical records be found? Observations During Initial Interview? 1. Is their height and weight within normal range? 2. Do they have difficulty ambulating? 3. Are there obvious deformities as a result of the fracture? 4. Do they need assistive devices for mobility (cane, crutches, brace, etc.) Common Functional Limitations: 1. Upper extremities: finger and manual dexterities, grasping, overhead activities. 2. Lower extremities: walking, bending, stooping, lifting, climbing, carrying, weight bearing on legs, pushing, pulling 3. General limitations: loss of strength, stamina, restriction of mobility Vocational Impediment Connection: The counselor needs to focus on the residual permanent functional limitations after the fracture has stabilized. Show how they have affected the individual in work, school, or other activities and/or show how the limitations will affect the individual in future job selection. Goal of Employment Considerations: Medical Aspects Notes 75 Consider what the individual needs to have the ability to retain or otherwise acquire needed skills for jobs he or she can handle with the remaining functional capacities. IPE Considerations: 1. Consider occupational therapy 2. Consider physical therapy 3. Consider the provision of necessary prosthetic devices 4. Consider goals that will not exacerbate the condition Medical Aspects Notes 76 CARPAL-TUNNEL SYNDROME Initial Interview Questions: 1. What types of problems are they having currently in a work situation or in other situations because of the disorder? 2. What types of jobs have they done in the past (A detailed job history is necessary.) 3. What kind of treatment have they had for the disorder and what type of treatment is planned? Observations During Initial Interview: 1. Is the individual able to grasp and hold objects in the affected hand? 2. Do they use the affected hand to write or sign their name? 3. Is there any observable scarring from a previous surgery? Common Functional Limitations: 1. Fingering 2. Lifting 3. Strength 4. Pain 5. Grasping 6. Dexterity 7. Reaching 8. Endurance Vocational Impediment Connection: Most individuals with carpal-tunnel syndrome apply for services because functional limitations caused by the disability make it very difficult or impossible for them to do their current or previous job. Often their physician has recommended they find a new vocation. Their previous vocational history must, however, be explored Medical Aspects Notes 77 to see if they have transferrable job skills. The individual may have skills to enter other employment consistent with their capacities and abilities which would not require duties that affect their disability. Goal of Employment Considerations: Consider if it is possible for the person to continue in their previous occupation with a job accommodation. Consider if the individual has the ability or potential to enter other occupations compatible with their transferrable skills. If training is necessary consider if the individual has the work personality and capabilities to succeed in a training program. IPE Considerations: 1. Client should follow medical treatment as recommended by physicians. 2. Consider restructuring job duties or redesigning the work station to assist the client return to their former employment. 3. Carefully analyze the specific job duties of potential employment goals to ensure the duties are compatible with client limitations. Medical Aspects Notes 78 LOW BACK PAIN Initial Interview Questions: 1. What caused the disability and what kinds of treatment have they had? 2. What are their limitations? (lifting, walking, standing, sitting, etc.) 3. What kinds of problems have they had in daily activities or in recreational activities? 4. Do they have pain? a. What activities seem to cause pain? b. What do they do to relieve pain? c. Are they taking medications? If so, how long, how much, how often and what are the side effects? d. Do they use alcohol to relieve symptoms? 5. Describe what they currently do in a typical day? 6. Do they have any problems sleeping? 7. How has the disability caused them problems at work? 8. Do they have any problems driving a car? 9. Do they use assistive devices (back brace, crutches, etc.)? Observations During Initial Interview: 1. Are their obvious indications of pain? 2. Do they continuously shift positions? 3. Do they sit or stand primarily and for how long? 4. Is their weight above normal? 5. Are there any problems seen with stamina? 6. Consistency of reporting symptoms (Do they appear to have the restrictions they claim?) 7. Does there appear to be a psychological response to pain, e.g., depression? Medical Aspects Notes 79 8. Is there any outstanding litigation? Common Functional Limitations: 1. Sitting 2. Standing 3. Bending 4. Twisting 5. Lifting 6. Climbing 7. Carrying 8. Stamina 9. Pain 10. Activities of daily living in severe cases 11. Additional limitations caused by side effects of medication 12. Driving a vehicle for long periods Depending upon the course of treatment, individuals may have learned a major means of avoidance of pain is the use of various pain medications. The counselor needs to be sensitive to an individual who may use alcohol in conjunction with these pain medications to increase the effects of the analgesic with the drug alcohol. A general statement is that there is a clear relationship between pain/disability and poor response to treatment. If two or more months of no improvement occur, then the counselor needs to consider the influence of psychological factors in the continuance of pain. This does not mean that the pain is not real, it means rather that there needs to be consideration of physical in the treatment and ultimate rehabilitation but also in the necessary response to psychological factors contributing to the adverse response to pain. There is a tremendous amount of controversy regarding the functional limitations associated with lower back conditions and the various treatments associated with these. If surgery is Medical Aspects Notes 80 completed, it is most likely to be a laminectomy which is the removal of the herniated fragment of the disk. All treatment requires careful monitoring by the physician and compliance on the part of the patient. These individuals do experience pain, regardless of the objective physical findings, the counselor rarely faces a pure case of malingering. The counselor needs to be sensitive to the issue that many individuals who experience lower back pain may currently be in various cycles of psychological adjustment related to their own self-image, i.e., often having jobs paying relatively large salaries or hourly wages but requiring heavy, and in some cases risky, physical activity which is counter-indicated by their back pain and facing the option of low paying but non-risky jobs. Vocational Impediment Connection: The individual probably needs a job which can accommodate frequent change of body position. Hence, if they have had a history of primarily work in jobs which require a high degree of lifting and physical activity, they may need job modifications or a less physically active job. Document if the there is a long history of back problems or if the problem is a result of muscle strain and is temporary. Consider how their disability will affect them in school functions or everyday activities, especially, if the person has never worked or has a limited work history. Goal of Employment Considerations: Consider whether the extent of pain of the individual can be overcome by pain management techniques, work hardening programs or by identifying a work goal which does not aggravate the condition. Also consider whether the individual has the capacity to train for appropriate work goals if required. IPE Considerations: 1. Follow recommended treatment 2. Consider diet or weight reduction as needed 3. The goal should be chosen giving careful consideration to the physical limitations 4. Consider job site engineering or accommodations 5. Consider work hardening programs. Physical conditioning/stamina building in some form may prove Medical Aspects Notes 81 beneficial 6. Consider pain management 7. Assess and deal with any secondary problems such as depression, or chemical dependency Medical Aspects Notes 82 AMPUTATIONS Initial Interview Questions: 1. Does the individual have a history of diabetes? 2. Does the individual have a history of vascular disease? 3. Does the individual wear a prosthesis? a. When fitted? b. Condition? c. Does it fit properly? e. Training on mechanics/usage of prosthesis? 4. What is the condition of the stump? Swelling? Sores? Has the individual been instructed in stump care? 5. Length of stump (above or below the joint)? 7. Does this affect the dominant extremity? Is there a need to learn to do things with the non-dominant extremities 7. Has the individual had physical and/or occupational therapy? 8. Can the individual operate a vehicle? Are there modifications? 9. Has there been a fluctuation in weight recently and is the weight within the normal range? Observations During Initial Interview? 1. If the individual wears a prosthesis, it utilized adequately? 2. Does the individual appear to have acceptable hygiene and cleanliness? 3. What is the individual's self-image and general affect? Common Functional Limitations: 1. Upper extremity a. Grasping b. Fingering c. Pinching d. Bi-manual activities e. Carrying Medical Aspects Notes 83 f. Lifting g. Holding h. Pushing 2. Lower Extremity a. Balancing b. Climbing c. Walking (even and uneven surfaces) d. Stooping e. Pushing f. Pulling g. Carrying large objects h. Lifting heavy or bulky objects i. Jumping 3. Upper and Lower Extremity a. Sudden jarring/trauma to stump area b. Extreme environmental conditions (heat, cold, humidity, dirt, etc.) to prosthesis wearers Vocational Impediment Connection: If the disability is a result of a recent injury the counselor should assess the resulting limitations as the relate to the individual returning to former employment. Will they be able to resume former work activities? Will they need to rely on newly acquired prosthetic devices which will in turn require adjustment? If the disability is of long standing nature the counselor should determine whether the individual could perform job duties adequately in past jobs. If the individual could perform necessary job duties it would be difficult to show a vocational impediment unless there are other factors, e.g., the condition is worsening or the job is aggravating the condition. If the individual has little or no work history the counselor should assess the specific limitations and compare them to ways in which they affect the individual's work future. Goal of Employment Considerations: The counselor should consider the willingness of the individual to use their prosthesis or appliance as needed to attain employment. The counselor should also be aware of the condition of the stump and prognosis of stability or if there is a probability of vascular complications. Consider driving aids that are available to solve potential transportation problems. Medical Aspects Notes 84 IPE Considerations: 1. Proper stump care/cleansing is essential to prevent irritation and infection. The client should be trained in this procedure by a physician. 2. The provision of necessary prosthesis should be individualized and fitted to a person based on their particular needs. The client should be sent to a physician (physiatrist or orthopedic surgeon) who is especially skilled and familiar with prosthesis fitting/prescription. Fabrication of this prosthesis should be performed by a certified prosthetist. 3. Consider that lower limb amputees who utilize a prosthesis for ambulation, expend great amounts of energy when walking, therefore, this may suggest a wheelchair for employment, if mobility is important in the situation. Medical Aspects Notes 85 ARTHRITIS Initial Interview Questions: 1. What is the prognosis? 2. What type of arthritis (e.g., rheumatoid, osteoarthritis, etc.)? 3. Which joints are affected? Have the individual explain affected range of motion. 4. What activities produce pain/stiffness? 5. Are there environmental conditions which produce pain/stiffness? 6. What type of treatment has the client had (e.g., surgery, PT, prosthesis) and how successful was it? 7. Has the individual had x-rays taken? When? Where? 8. What medications are they taking and what are the side effects? Observations During Initial Interview: 1. Notice any obvious signs of swelling, redness, or joint deformity. 2. Does the individual have noticeable restriction of motion in walking, signing forms, bending to sit in the chair, standing, etc? 3. Is the individual in obvious pain? 4. (Back Conditions) How long did the individual sit and what was the degree of difficulty tolerating this position? 5. Does the individual appear to be overweight? 6. Does the individual exhibit any signs of chronic emotional stress, e.g., depressed mood? Common Functional Limitations: 1. Upper Extremities a. Fine hand movements Medical Aspects Notes 86 b. Fingering c. Manual dexterity d. Grasping e. Working over the shoulders f. Tactile discriminations 2. Lower Extremities a. Stooping b. Bending c. Twisting d. Lifting e. Crawling f. Sitting g. Balancing h. Kneeling i. Climbing j. Turning k. Carrying l. Standing 3. Either upper or lower extremities a. Abrupt extremes of weather/temperature conditions b. Strenuous activities without frequent rest periods c. Trauma/jarring/overuse of affected joints d. Pain e. Mobility Vocational Impediment Connection: The counselor should tie the specific functional limitations to the individuals problems in handling past job duties or show how the limitations would limit future employment opportunities. Specifically, note pain in performing tasks, mobility in performing tasks, ability to drive or access other modes of transportation, side effects of medications that may cause illness which interferes with daily work routine, jobs with temperature extremes that should be avoided or accommodated. Goal of Employment Considerations: These diseases display frequent undefined periods of time involving exacerbation or remission of symptoms. During remission, the client may have periods of time with few limitations. The counselor should be aware of which joints are affected and with the client decide which vocations would utilize less affected joints. A person with arthritis should have certain evaluations performed to aid in diagnosis and treatment. Medical Aspects Notes 87 An internist, especially a rheumatologist, is best equipped to provide this. If an individual has multiple range of motion difficulties, it could be very effective to also utilize a physiatrist to evaluate the client's range of motion and muscle strength. The counselor should always insist, however, that the physician provide information about the client's range of motion, muscle strength, and weakness of affected joints. IPE Considerations: 1. Participate in PT and/or OT as prescribed. 2. Take medications as prescribed. 3. Consider adaptations/modifications of home environment. 4. Consider job engineering and job site modifications 5. Consider independent living needs. 6. Consider referral to support groups Medical Aspects Notes 88 CARDIOVASCULAR Normal Structure Pericardium mitral valve (bicuspid) myocardium aortic semilunar valve endocardium aorta coronary arteries capillaries atria (chambers) sinoatrial node ventricles atrioventricular node tricuspid valve systole (contracting 100-140) pulmonary semilunar valve diastole (expansion 80-90) pulmonary artery pulmonary veins Disorders Hypertension stenosis primary(essential) Endocarditis malignant Pericarditis - tamponde fluid Arteriosclerosis (leading cause of Rheumatic Heart Disease illness and death, plaque) autoimmune stenosis streptococcus thrombus embolus PERIPHERAL VASCULAR CONDITIONS angina pectoris Peripheral Atherosclerotic Aneurysm Disease dissecting (Arteriosclerosis Obliterans) Congestive Heart Failure collateral circulation myocardial infarction intermittent claudication (leg dyspnea (nocturnal) cramps) edema necrosis Arrythmia Thromboangitis Obliterans tachycardia (fast) (small and medium blood bradycardia (slow) vessels) SA block Burger's Disease (20-40, AV Block smoking) syncope palpitations Raynaud's Disease Coronary Artery Disease vessel spasms ischemia (anoxia) Venous Thrombosis necrosis (Thrombophlebitis myocardial infarction Phlebitis) Valvular Heart Disease Vericose Veins mitral/tricuspid/aortic prolapse regurgitation insufficiency incompetency Medical Aspects Notes 89 Diagnostic Chest X-ray venogram fluid (in lungs) cardiac angiogram hypertrophy (enlarged) radiologist Electrocardiography (ECG) Echocardioography rhythm ultrasound damage Radionuclide Imaging medications (monitor) Cardiac Catheterization Holter Monitor (fluorscope - dye) Cardiac Stress Test CPK activity Blood Serum ergometer Cardiac enzymes Angiogram arteriogram Treatment Medical Surgical antihypertensive coronory angioplasty diurectics coronary bypass antiarrhythmics Pacemakers nitroglycerin fixed rate, demand, or standby anticoagulants synchronous digitalis bifocal Transplantation immunosuppressants PsychoSocial fear denial anxiety reactions Family depression support inactivity overprotection isolation recreation withdrawal hidden disability Life Style diet long-term treatment alcohol medication smoking sexuality exercise Vocational good prognosis isometric exercise heat rest patterns cold Medical Aspects Notes 90 CARDIOVASCULAR DISORDERS AND PERIPHERAL VASCULAR DISEASE Initial Interview Questions for Cardiovascular Disorder: 1. What are their symptoms? Have them describe how it makes the feel (i.e., short of breath, chest pain, weakness, fatigue, sleep patterns, etc.) 2 What activities cause symptoms? How long do symptoms last? How debilitating are symptoms (i.e., slow down activity, stop all activity)? How do symptoms subside? 3. What does the physician tell them are their specific functional limitations? 4. Do they have a history of high blood pressure? How high? 5. What do they know about the disorder? 6. Have they ever had periods of dizziness? Rapid or irregular heart rhythm? 7. What is their emotional state, e.g., fear of further problems, depression? 8. What recent diagnostic studies have been done (i.e., ECG, Holter Monitor, cardiac catheterization, angiogram, echocardiogram, radionuclide imaging)? When? Where? Who is/was the treating physician? 9. What treatment have they had (i.e., medications, surgery, pacemaker)? If prescribe medication, what is the purpose of the medication? Who is the prescribing physician? What type of physician? Do they experience drowsiness or other side effects? 10. Can they climb a flight of stairs without pain, discomfort, or shortness of breath? 11. What has their physician asked them to do regarding their condition e.g. diet, smoking, physical activity etc? Do they follow the physicians advice? Initial Interview Questions for Peripheral Vascular Disease: 1. Do they have leg pains; which leg? a. Area of leg affected b. Frequency of attacks Medical Aspects Notes 91 c. Activity level achievable during pain d. Duration of pain 2. Do certain types of activities initiate pain? 3. Do they experience swelling at or below the affected area, skin discoloration, skin texture changes (rough, smooth), loss of leg hair, etc.? 4. Do they take medication for this condition or for pain? If so, what kind of medication and for what purpose is it taken? Who has prescribed the medication and what type of physician is she/he? How recent are the prescriptions? 5. What activities relieve pain (e.g., rest, exercise, heat, elevation)? 6. What has their physician asked them to do regarding their condition, e.g., diet, smoking, physical activity, etc? do they follow the physician's advice? Observations During Initial Interview: 1. Did they exhibit fatigue or shortness of breath? 2. Did they smoke? 3. Do they appear overweight and has their physician recommended weight loss? 4. Did they have any coughing? 5. Do they use assistive devices (e.g., cane, wheelchair, walker, etc.)? 6. Were their ankles swollen and did they have varicose veins? 7. Was their any skin discoloration or ulcerations? 8. Did they appear to be in pain? Common Functional Limitations: Obtain a good definitive description of limitations from their physician. 1. Mobility (walking, running, climbing stairs, etc.) 2. Standing for prolonged periods. Has the physician Medical Aspects Notes 92 contraindicated standing? 3. Lifting, pushing, pulling, reaching, pressing, etc.? Does the individual have a back problem? 4. Stamina 5. Endurance 6. Temperature extremes 7. Dizziness. If so , under what conditions? 8. Tolerance to environmental changes (i.e., gases, fumes, air quality, altitude changes, etc.)? Vocational Impediment Connection: Consider those functional aspects of work which are limited or excluded or contraindicated due to the presentation of this disorder. Consider also whether the client fatigues easily or requires long rest periods between exertions? Is this client susceptible to ulcerations or vascular damage due to ischemia when standing? Goal of Employment Considerations: Consider their age, limitations, training, etc.? Many persons with cardiovascular disorders have a good prognosis for employment provided they cease smoking, lose weight, maintain moderate exercise, and reduce stress, per physician recommendations. Lifestyle changes are an important part of the medical management of these disorders. In determining employment goals, the counselor must look at abilities and aptitudes in relation to potential goals that are not contraindicated by the restrictions of their disability. Side effects of medications must also be assessed. IPE Considerations: 1. Assure that their physician cleared them to work and clearly identified activities to be avoided. 2. Make sure the individual has an adequate understanding of the disorder through counseling. (Some individuals often have great fear of exacerbations.) Assure their support system is in place, and activated to assist with medical management and support of the individual. 3. In planning, consider what are the best exertion/rest patterns and what time of day do they occur, (i.e., morning, afternoon, evening, combinations, etc.). 4. Give first consideration to returning the individual to Medical Aspects Notes 93 their former employment. Consider job site modifications. 5. In the job placement effort consider work environment requirements (i.e., gases, fumes, dust, stairs, hard surfaces for walking, frequent cuts, bruises, etc.) 6. In the job goal and in the placement effort give full consideration to the activities which must be avoided. The individual ultimately needs to be placed in a position where they are not performing duties which their physician has advised against. Medical Aspects Notes 94 RESPIRATORY Normal Structure respiration epiglottis (flap, food) inspiration trachea expiration (carbon dioxide) cilia thoracic cavity bronchi diaphragm bronchioles pleura (friction) alveolar sacs pharynx alveoli larynx Disorders Upper Respiratory Tract Disorders hypertrophy pharyngitis edema laryngitis Bronchiectasis sleep apnea purulent central- Occupational Lung Disease peripheral- silicosis mixed- fibrosis Bronchial Asthma hypoxemia dyspnea pneumoconiosis (black lung) atelectasis asbestosis status asthmaticus berylliosis (flourescent Chronic Obstructive Pulmonary Disease lights) (COPD) byssinosis (textiles) bronchitis asthsma mucus Tuberculosis alveoli anorexia emphysema hemoptysis enlargement miliary hypoxemia Cystic Fibrosis hypercapnia Chest Injuries polycythemia pneumothorax phlebotomy hemothorax (thoracocentesis) cor pulmonale (right ventricle) Diagnostic Chest X-Ray forced expiratory volume bronchoscopy residual lung volume laryngoscopy maximum voluntary ventilation skin tests tidal volume mantoux inspiratory capacity pulmonary angiography functional residual capacity Pulmonary Function Tests ventilation/perfusion scan spirogram Medical Aspects Notes 95 Treatment irreversible expectorants control symptoms steroids avoid irritants intermittent positive pressure percussion breathing (IPPB) machine bronchodilators oxygen antibiotics pneumonectomy diuretics PsychoSocial Fear changes in cognitive anxiety functioning inactivity sick role helplessness guilt related to smoking despair stigma of tuberculosis depression social isolation sexuality Life Style obesity adequate humidity smoking avoid upper respiratory extra time to complete activities infections avoid extreme temperatures and flu Vocational irritant factors lifting walking carrying Medical Aspects Notes 96 RESPIRATORY DISORDERS Initial Interview Questions: 1. Is the condition progressive and how rapidly? 2. Do they have excessive coughing attacks? Shortness of breath? Chest Pain? Any sputum? If so, how much? 3. What activities cause them shortness of breath? How much of that activity is required to cause shortness of breath? 4. Can they climb stairs? If so, how many? 5. Can they walk one level block without rest? 6. Do they have trouble with activities of daily living (i.e., dressing, cleaning bathing, talking, etc.)? 7. What relieves their shortness of breath? Medication? Rest? 8. Do they take medication of any kind? If so, what kind, what is its purpose, who prescribed it? Is the physician a specialist other than a G.P.? What are the side effects e.g. nervousness, sleep problems etc.? 9. Do they smoke? 10. Have they undergone pulmonary function tests, x-ray, bronchoscopy, laryngoscopy, spirometer, pulmonary angiogram, radionuclide scan, skin tests, lung scan? If so, when, where, who was the physician and what type of physician was he/she? 11. Have they been evaluated for cardiovascular problems in the past year? 12. Have they had a history of asthma? Respiratory infection? If so, describe. Is the history cyclical, occurring more often, recently? 13. Do they have any allergies (i.e., pollens, dust, mold)? If so, describe reactions to allergies (allergy attacks). 14. Do they have difficulty in seasonal or environmental extremes (i.e., cold, heat, humidity, high altitude)? If so, describe difficulties and circumstances. 15. Do they have problems sleeping? Medical Aspects Notes 97 Observations During Initial Interview: 1. Did they appear fatigued, have shortness of breath, or show abnormal color in their face? 2. What was their posture (sitting upright, attentive, or slouched, eyelids droopy, etc.)? 3. Was there any excessive amounts of wheezing, coughing, or expectoration? 4. Was there any abnormal coloration in lips or fingernail beds, etc.? 5. Do they have an obvious chest deformity? 6. Did they appear overweight, underweight, and/or weak? 7. Do they experience edema in ankles or cardiovascular problems? 8. Describe their general behavior (cooperative, willing, or short yes/no answers, resistant, etc.). Common Functional Limitations: 1. Walking 2. Climbing 3. Stamina and strength 4. Tolerance to temperature changes/extremes 5. Wet and humid conditions 6. Fumes/dust/mold/gasses 7. Pushing/pulling 8. Lifting Vocational Impediment Connection: If the individual has a work history describe the characteristics of the disorder which causes them difficulty in performing the duties of those jobs or caused them to lose jobs. If little or no work history, explore how the functional limitations might limit the vocational choices for them or how Medical Aspects Notes 98 the limitations might cause them problems preparing for a job consistent with their abilities. The potential need for air purity at the work site or their need for rest during the work day are also considerations. Goal of Employment Considerations: Explore what may need to take place for this person to start or return to employment carefully. What types of employment might be suitable for this individual based on previous cycles of exacerbation and fatigue? Do they have the abilities or aptitudes for such employment? Also consider the worksite environment that may be necessary considering their need for rest, air purity, possible absenteeism due to cycles of exacerbation. IPE Considerations: 1. Develop an understanding, with the client, through counseling of the disorder and its realistic functional limitations. Assure the client has an accurate knowledge of the disorder along with knowledge of techniques to deal with panic attacks and exacerbations. 2. Compliance to the medical management plan to include the cessation of smoking. 3. In choosing the job goal give careful consideration to the environmental irritants, or conditions, which may exacerbate the disorder (i.e., fumes, dust, pollens, cold air, temperature extremes or changes, air quality, etc.). 4. Each client will have special considerations, such as, diets, weight loss, medications, and avoidance of humid environments, depending on the nature of the disorder. Plans need to incorporate all facets of the persons life, such as, support systems, employment options, rest patterns, and so on. 5. In the actual job placement phase selective job site placement will be necessary to assure the appropriate work environment and work flexibility required by the client. Medical Aspects Notes 99 ASTHMA Initial Interview Questions: 1. Does the individual have excessive coughing attacks or shortness of breath? 2. What activities cause shortness of breath? 3. What relieves the shortness of breath, e.g., medication, rest? 4. What specific activities are difficult for the individual because of the disorder (climbing stairs, walking, dressing,etc.)? 5. How often does the individual experience asthmatic attacks? 6. What types of medication does the individual take? 7. Are there any know allergies such as pollens, dust, mold, or fumes? 8. Does the individual have any difficulty in temperature extremes especially cold? 9. How incapacitating are their attacks and how long is the recovery period? 10. How does the individual respond to the fear of a potential attack? 11. Does the individual smoke? 12. What exposure do they have to the world of work? Observations During the Initial Interview: 1. Does the individual have shortness of breath? 2. Did they wheeze or cough? 3. Did they use inhalants or other medications during the interview? Common Functional Limitations: 1. Walking Medical Aspects Notes 100 2. Climbing 3. Lifting 4. Stamina 5. Cold 6. Temperature changes 7. Wet, humid conditions 8. Fumes and dust Vocational Impediment Connections: It is important for the individual to avoid allergens which are causing the reaction or to avoid the nonallergen stressors that precipitate the asthma attacks. Therefore, because of the conditions related to former employment, the individual may need services to redirect them into new vocations. In addition, they many be very limited in the types of jobs available to them because of the conditions they must avoid. They may also have a vocational impediment based on the recovery time necessary after experiencing an asthma attack. Goal of Employment Considerations: Employment goals center around identifying jobs for which the individual has potential yet also offer an appropriate work environment in which allergens or stressors can be avoided. The frequency of asthma attacks and the recovery time might be an issue to consider. IPE Considerations: 1. Avoidance of the allergen or the stressors causing the reaction. The vocational goal needs to be chosen with those in mind to assure an appropriate work environment e.g., avoid extreme temperatures, smoke, etc.. 2. The individual should adhere to the medication regime prescribed by their physician. 3. In some cases, relaxation therapy and/or assertiveness training may help relieve stressors which precipitate attacks. Medical Aspects Notes 101 ALLERGIES Initial Interview Questions: 1. What exactly is the individual allergic to? 2. What types of allergic reactions do they have? 3. When do the reactions normally occur and how long do they last? 4. Is the individual taking medication and how does that affect them? 5. Describe how the allergy has affected them in past work places. 6. In what way does the allergic condition affect their ability to obtain or maintain employment? 7. How do they compensate for the allergen in the work place, e.g., protective clothing, goggles, etc.? Observations During Initial Interview: 1. Are there any obvious physical symptoms such as skin irritation, nasal discharge, sneezing, coughing, or wheezing? Common Functional Limitations: 1. Outside work 2. Wet, humid conditions 3. Fumes and dust 4. Stamina 5. Fatigue 6. Pain 7. Sleepiness 8. Motor coordination Medical Aspects Notes 102 Vocational Impediment Connection: Most allergic conditions would cause little or no vocational impediment for individuals. Treatment usually consists of avoidance of the allergen and possible use of medications. The key for eligibility purposes would be to show that the individual is truly prohibited for doing the type of work they have done in the past or that their vocational alternatives are truly limited by the conditions they must avoid. The connection is much easier to make with someone who develops a condition after establishing a work history. It would be difficult to establish this relationship for individuals who have never worked or have limited work experience such as students in high school unless the condition is severe and greatly restricts their vocational choices. Side effects of medications may contribute to a vocational impediment. The side effects may impair motor coordination, fine motor coordination, ability to operate equipment, and may cause drowsiness. Goal of Employment Considerations: Individuals who avoid responsible allergens and follow their prescribed regime of medications can be expected to have few problems. The key is finding the appropriate work environment which would avoid the responsible allergens to the greatest extent possible. IPE Considerations: 1. The most important consideration is the vocational goal chosen. The environment in which the individual will work should be as free of responsible allergens as possible. 2. The individual should adhere to the regime of medications as prescribed. 3. Consider job place accommodations, e.g., air purifiers, etc. Medical Aspects Notes 103 RENAL & URINARY TRACT Normal Structure renal capillaries urinary tract renal veins ureter glomerular urethra filtration (calyx) urinary meatus urea cortex (out) amino acids medulla (inner) electrolytes renal pyramids renal pelvis nephrons Functions: glomerular filtering capillaries reabsorbing Bowman's capsule homeostasis (electrolytes) glomerulus substances renal arteries (1/4 blood) regulate blood pressure peritubular Disorders Cyctitis Nephrosis (Nephrotic Syndrome) hypertention Hyperproliferation bacteremia Acute Glomeruleonephritis Urinary or Renal Calculi (Kidney proteinuria stones) Polycystic Kidney Disease Hydronephrosis Renal Failure (End Stage Renal Acute Nephritic Syndrome Disease) nephritis acute failure glomerulonephritis thrombus streptococcal pharyngitis chronic failure endocarditis nephrosclerosis hematuria proteinuria dysuria oliguria Pyelonephritis pruritus edema uremia septcemia anuria pericarditis tamponade endocarditis peripheral neuropathy anasarca (generalized edema) Diagnostic Urinalysis blood concentration bacteria acidity urine culture protein Blood Urea Nitrogen Determination sugar Medical Aspects Notes 104 Diagnostic con't Serum Creatinine Determination Cystoscopy Creatinine Clearance Test Retrograde Pyelography Kidney, Ureters, & Bladder x-ray Renal biopsy Intravenous Pyelography Renal Arteriography Treatment Lithotomy peritoneal hemodialysis litholapaxy continuous ambulatory peritoneal nephroscopy dialysis pyelol-lithotomy continuous cycling peritoneal nephro-lithotomy (calyx) dialysis ureter-lithotomy peritoneal dialysis extra-corporeal shock wave intermittent peritoneal dialysis lithotripsy Arteriovenous shunt (cannula) nephrectomy Arteriovenous fistula dialysis Renal Transplantation Psychosocial end-stage renal failure denial profound impact suicide elevated toxins fear of death cognitive anger speech hostility lethargy conflicts severe depression sexuality Lifestyle diet fluids Vocational End Stage Renal Failure is peripheral neuropathy progressive lifting impaired judgment dialysis schedules Medical Aspects Notes 105 RENAL AND URINARY DISORDERS Initial Interview Questions: 1. Do their problems relate to difficulty with urination? 2. Do they have difficulty with kidneys or prostate? 3. Are infections involved? 4. Has the individual had any history of hypertension or diabetes? 5. Is he/she on dialysis? Describe frequency, type, and when (hours of the day) the individual is involved in dialysis? Do they anticipate dialysis in the near future? Do they have confusion or memory loss between treatments? 6. What medications do they take? For what purpose? Name and type of physician who prescribed medication? 7. Has there been a kidney transplant? Are they taking antirejection medications and if so are there side effects? 8. Is a transplant recommended or planned? Observations During Initial Interview: 1. What is their height and weight? 2. Do they have excessive swelling or bloating of the body? 3. Do they seem to be alert and able to concentrate? 4. What was the individuals energy level and affects? Common Functional Limitations: 1. Endurance 2. Stamina 3. Concentration 4. Lifting 5. Climbing 6. Long hours without rest Medical Aspects Notes 106 7. Heavy exertion 8. Ability to sleep 9. Alertness 10. Exposure to heat for prolonged periods 11. Pulling 12. Pushing 13. Problem solving/decision making 14. Dialysis schedule interruptions Vocational Impediment Connection: If the individual is on dialysis they may need a work schedule to accommodate this need. Often more physical jobs must be ruled out and sedentary employment is more appropriate. Dependency on dialysis may bring about emotional problems, e.g., depression, anxiety, panic attacks, etc.. Goal of Employment Considerations: Dialysis schedule interruptions need to be considered. Employment must be consistent with their abilities and aptitudes between dialysis treatments. Their work personality is critical. Often there is a disincentive to work with end stage renal disease as they qualify for SSDI and medicare. Their work personality should be fully explored. IPE Considerations: 1. Family support is critical. Consider referral to a support group. 2. Modification of risk factors, e.g., alcohol use, environmental toxins, use of salt, etc.. 3. Follow treatment as prescribed by physicians. 4. Consider transportation needs. 5. The vocational goal may depend on flexibility of hours needed to attend dialysis treatments as well as in feeling well enough to work. Medical Aspects Notes 107 DERMATOLOGIC SYSTEM Normal Structure epidermis sebaceous glands melanocytes sweat glands melanin adipose tissue dermis Disorders dermatitis carcinoma erythema malignant melanoma edema Burns: pruritis (eczema) thermal contact dermatitis chemical allergic reactions radiation hives (urticaria) electrical psoriasis Burn depth: skin infections superficial (first degree) herpes zoster (shingles) Rule of Nines skin cancers: Lund Browder Method basal cell Diagnostic biopsy patch tests scrapings Wood's Light cultures examination smears (ultraviolet) Treatment Medications: prevent complications topical sepsis antifungal eschar antibiotic debrided antibacterial necrotic tissue antiviral nutrition needs antipruritics contractures corticosteroids Biological Dressings: systemic xenograft (heterograft) Dressings: homograft therapeutic baths or soaks synthetic graft light treatment (phototherapy) autograft Burn Treatment: split-thickness graft stabilizing full-thickness graft restore fluid balance PsychoSocial appearance as perceived by others anxiety self-conscious emotional stress anger loss of desirability guilt attractiveness regret affect resentment Medical Aspects Notes 108 PsychoSocial con't sexuality unrealistic expectations depression Life Style avoidance of irritating substances loss of vision contractures self-conscious feelings Vocational irritating substances compression garments stress excessive warmth sunlight dryness attitudes of coworkers humidity hospitalizations air pollution Medical Aspects Notes 109 BURNS Initial Interview: 1. As a result of the burn are there limitations? Describe. 2. As a result of the burn are there limitation in upper extremity function (e.g., reaching, grasping, finger dexterity, the sensation of touch, etc.)? 3. What joints and extremities are limited? How? 4. Have the individual describe treatment (past and present). Dates of treatment? Where? 5. Is the individual required to wear compressive garments? What type? Length of wear? 6. Name of the individual's primary care physician? Type of physician Date last seen? Observations During Initial Interview: 1. Obvious signs of disfigurement (i.e., facial characteristics, hair loss, contractures, hypertrophic scarring, eye/eyelid dysfunction). 2. Evidence of scars on visible areas (i.e., face, neck, hands, arms). 3. Did the individual exhibit signs of depression or problems of self-image? Common Functional Limitations: Burn injuries most commonly limit mobility. This results from contractures caused by shortening of tissues or scarring. Burns to the lower extremities may interfere with walking, climbing, or balancing. Those to the upper extremities may interfere with reaching, fingering, and handling. In some cases, upper extremity impairment also results in problems with self- care activities such as eating, dressing, hygiene, and grooming. Cosmetic disfigurement is also a common result of burn injuries. Family members, co-workers, and the public may reject the person. This can present a barrier to employment in occupations requiring interpersonal relationships. Other common functional limitations include: Medical Aspects Notes 110 1. Tolerance to extreme heat. 2. Aesthetic appearance. 3. Ability to meet the public 4. Activities causing trauma/irritation to injured skin and/or joints. 5. Range of motion if joints re affected (see arthritis limitation). 6. Self-image 7. Employer/peer acceptance Vocational Impediment Considerations: The specific functional limitations must be addressed as they relate to the performance of past jobs or potential jobs. Cosmetic appearance can be an employment barrier when there is potential for rejection from co-workers, employers, and the public. Goal of Employment Considerations: The counselor should assess the extent of functional limitations as they relate to performing past jobs. If unable to perform past work, an assessment must be made as to the individual's potential for further training to qualify for employment consistent with their limitations. IPE Considerations: 1. If compressive garments are worn, consideration should be given to avoid vocational training or work environments with high temperatures or humidity. 2. Manual and finger dexterity will be affected if they are required to wear protective gloves. 3. Clients should be educated as to garment care and conditions to avoid which would reduce the life of the garments. 4. Rehabilitation planning should take into account potential needs for physical therapy and possibly reconstructive surgery, to treat contractures. Similarly, cosmetic surgery may be needed to reduce disfigurement. 5. In some cases, adaptive equipment and devices may be needed Medical Aspects Notes 111 to compensate for lost or impaired functioning. Burned skin is not as strong as normal skin, and depending on the area of the body involved, occupations likely to irritate exposed areas might need to be avoided. 6. Additionally, since burned skin does not insulate well, the person may need to avoid occupations where he or she is exposed to very high or very low temperatures. Medical Aspects Notes 112 GASTROINTESTINAL DISORDERS Normal Structure Alimentary canal liver Buccal cavity 1) glucose, glycogen Saliva, parotid, submaxillary and 2) protein, urea sublingual glands bile, fat Pharynx 3) red blood cells Esophagus 4) clotting substance Peristalsis 5) detoxification center Peritoneum bilirubin Cardiac sphincter hepatic artery Stomach portal vein Pyloric sphincter gallbladder Duodenum hepatic ducts Jejunum cystic duct Ileum common bile duct Ileocecal valve pancreas Ascending colon pancreatic duct transverse colon descending colon sigmoid colon rectum anus Disorders esophagitis dyspepsia stress Gastritis Hernia Peptic Ulcer inguinal duodenal ulcer femoral gastric ulcers incarceration epigastric pain strangulated hematmesis Pancreatitis melena cholelcystitis perforation cholelithiasis peritonitis jaundice Curling's ulcer Hepatitis Cushing's ulcer hepatitis A (food or water) Inflammatory Bowel Disease with hepatitis B (serum) remissions and exacerbations injection Crohn's hepatitis non-A, non-B ulcerative colitis transfusion stenosis jaundice edematous hyperbilirubinemia diverticulitis chronic hepatitis Irritable Bowel Syndrome toxic hepatitis (Spastic Colon, Mucous Colitis) Cirrhosis ascites Diagnostic Medical Aspects Notes 113 Barium swallow Cholecystography Barium enema Cholangiography Esophageal manoscopy Abdominal sonsography Gastroscopy, endoscopy CAT scan Colonoscopy, protoscopy, Radionuclide imaging sigmoidoscopy biopsy abdominal paracentesis laproscopy Treatment diet Inflammatory Bowel Disease cease smoking steroids Peptic Ulcer sulfonamide vagatomy anastomosis pyloroplasty colectomy gastroenterostomy ileostomy antrectomy stoma subtotal gastrectomy colostomy Kock pouch ileooanal pouch PsychoSocial Eating associated with pleasure Body concept/image Elimination associated with privacy And cleanliness Psychological issues aggravate the Gastrointestinal functioning Life Style Restriction of diet Alcohol prohibited Fear of sexual intimacy Care given by family members Vocational No special work restrictions Erratic schedules interfere with meals stress Medical Aspects Notes 114 GASTROINTESTINAL DISORDERS Initial Interview Questions: 1. Describe the nature of your gastrointestinal disorder (e.g., hernia, ulcer, colitis, hepatitis, etc.). 2. Do you have bowel and/or bladder problems? 3. What treatment have you had for your disorder? Describe the physician's prescribe treatment plan and prognosis. What type of physician was he/she? Where are they located? 4. What medications are you taking( e.g, antacids, antiemetics, digestants, antidiarrheals, laxatives, cathartics, anticholinergics, antimicrobials, etc.)? What are their side effects? Are you following the medication schedule? 5. Describe how the disorder has affected your work history? 6. Are there stressors contributing to the exacerbation of the disability? Can these stressors be removed or reduced? 7. If hepatitis, does the person understand the importance of and responsibility of a healthy life? Observations During Initial Interview: 1. Do you see any evidence of physical problems (e.g., jaundice, fatigue, irritability, etc,)? 2. Does the person appear underweight? 3. Do you see any signs of emotional problems, (e.g., stress, fidgeting, hypersensitivity, etc.,)? Common Functional Limitations: 1. Lifting 2. Bending 3. Work schedules 4. Bowel and Bladder Control Vocational Impediment Connection: Medical Aspects Notes 115 In most instances, work restrictions are not necessary for individuals with gastrointestinal disorders. The key for eligibility purposes would be to show that the individual is truly prohibited for doing the type of work they have done in the past or that their vocational alternatives are truly limited by the conditions involving stressors they must avoid. The connection is much easier to make with someone who develops a condition after establishing a work history. It would be difficult to establish this relationship for individuals who have never worked or have limited work experience such as students in high school unless the condition is severe and greatly restricts their vocational choices. Goal of Employment Considerations: Individuals who avoid responsible stressors and follow their prescribed regime of medications can be expected to have few problems. The key is finding the appropriate work environment which would avoid the responsible stressors to the greatest extent possible. IPE Considerations: 1. The most important consideration is the vocational goal chosen. The environment in which the individual will work should be as free of responsible stressors as possible. 2. The individual should adhere to the regime of medications as prescribed. 3. For individuals with diverticular and hernia, the may need to look at avoiding activities that increase intra-abdominal pressure or look at available modifications. Medical Aspects Notes 116 CANCERS Normal Structure cells endothelial cells reproduction DNA epethelial cells genes Disorders 100 types of cancer Types: tumors: *carcinoma benign *sarcoma malignant *lymphoma mutation of DNA *leukemia anaplastic (less differentiated) *melanoma primary site Staging & Grading: primary tumor irregularity of shape metastasis indistinctness of cell outline secondary tumor Nuclear size Causes: increased mitosis *radiation TNM system *some chemicals, pollutants Tumor (T 0-4) *smoking and tobacco use Node (N 0-3) regional *some viruses Metastsis (M 0-3) *chronic physical irritation of a Tis (in situ) body part histological grading *ultraviolet rays (sun) pathologist *hereditary predisposition differentiated (more similar carcinogens to the cell of origin the hormonal secretions better prognosis) diet stress Diagnostic occult malignancies needle biopsy cancer screening incisional biopsy x-ray cytology (pap smear) mammography - positive diagnosis endoscopy requires microscopic examination nuclear medicine (histological testing) laboratory tests Diagnostic Surgery: alpha-feto-protein & carcino- exploratory embryonic antigens laparotomy Treatment cure - no evidence for 5 years curative adjuvant therapy palliative (prevention of metastasis) reconstructive palliative therapy simple (relief of symptoms) radical Surgery: Chemotherapy preventative Radiation therapy Biologic therapies Immunotherapy Medical Aspects Notes 117 Hormone therapy Gene therapy bone marrow transplant antineoplastic medications antiangiogenesis or inhibitors Treatment con't Side Effects: Urinary: damage of normal cells that grow surgery rapidly uretero-sigmoidostomy hair follicles (alopecia) cutaneous ureterostomy skin ilial conduit gastrointestinal lining urostomy bag bone marrow nephrectomy Radiation Therapy: Brain/Spinal Cord: external irradiation internal chemotherapy intracavity Lymphomas: interstitial Hodgkin's disease immunotherapy: non-Hodgkin's lymphomas bone marrow transplant irradiation Gastrointestinal: chemotherapy surgery & resection Multiple myeloma: Larynx: irradiation subtotal chemotherapy laryngectomy Leukemia (acute and chronic): laryngostomy ???? irradiation tracheostomy chemotherapy espophageal speech Breast: artificial larynx radical mastectomy irradiation chemotherapy lumpectomy Lung: partial or segmental mastectomy surgery lymphedema pneumonectomy breast reconstructions lobectomy prosthesis segemental resection irradiation chemotherapy PsychoSocial stigmatized fear threat to mortality withdrawal future independence anger recurrence hostility vulnerability denial loss of control synonym for death helplessness social perception depression alienation irritability Medical Aspects Notes 118 Life Style side effects of irradiation/chemo/ radical surgery effects on sexuality Vocational implications: independence financial affirmation of life self-esteem attitudinal barriers Medical Aspects Notes 119 CANCER Initial Interview Questions: 1. What kind of cancer do they have? 2. Have there been recent changes in their condition? 3. What is the physician's prognosis? 4. How is the cancer currently causing problems for the individual? 5. What modes of treatment have been used (e.g., surgery, chemotherapy, and/or radiation)? 6. What is their treatment regime and what medications do they take? 7. What are the side effects of their treatment and/or medications? 8. What are their specific functional limitations? 9. How does the individual view his/her vocational future? 10. Have they been able to handle medical expenses and what are the sources? Observations During Initial Interview: 1. Does the individual appear below normal weight? 2. Does there appear to be signs of loss of stamina or strength? 3. Are there visible signs of treatment or surgery (client coloring, hair loss, swelling)? Common Functional Limitations: Functional limitations related to specific types of cancer. The following are general functional limitations which are possible. 1. Stamina 2. Strength Medical Aspects Notes 120 3. Lifting 4. Climbing 5. Walking 6. Temperature changes Vocational Impediment Connection: The key to determining the vocational impediment is to relate the specific functional limitations for the individual to their ability to get or keep employment. The results or effects of treatment or therapy are an important consideration. There are times when the cure is worse than the disease in creating vocational impediments. The emotional status of the individual possibly including anxiety and depression may also play an important part in determining vocational impediment. Goal of Employment Considerations: Prognosis for the individual would be important. Although life expectancy rates for specific cancers are available and may be helpful, they should not be the basis for occupational choices. Instead medical information should be reviewed with the individual and possibly with the help of a medical consultant. Consider if the side effects of medical treatment will prevent the individual from participation in or completion of other necessary services. Consider where the individual is in their treatment and if there will be any amputations or other disfiguring treatments planned. IPE Considerations: 1. The IPE should include periodic medical evaluations. 2. Counseling may be considered as a part of the plan in order to deal with the possible psychosocial issues of a terminal illness. 3. Treatment (i.e., surgery, radiation, chemotherapy) should be planned as recommended by physicians. Medical Aspects Notes 121 ALCOHOL ABUSE/DEPENDENCY Initial Interview Questions: 1. Is the individual currently drinking? 2. What is the history of onset of their drinking? Discuss patterns (e.g., how often, how much, where, when, daily, weekends, etc.). 3. What is their prescribed treatment (where, when, number of admissions, periods of sobriety)? 4. What sobriety support systems do they use (family, significant other, AA, church, group)? 5. What is their legal status? Is this a court ordered referral (probation and parole, DWI safety intervention class, treatment center)? 6. Do they have a current valid driver's license? 7. Are they on current medications (prescribed Antabuse or non- prescribed) including type and effects? 8. What is their status concerning any psychological interventions (i.e., psychiatrist, psychologist, social worker)? 9. Have they had any arrests for DWI? 10. Have they used non-prescribed drugs other than alcohol? Observations During Initial Interview: 1. Does the individual seem agitated, depressed, euphoric? 2. Does the person appear to be intoxicated (e.g., odor of alcohol, slurred speech, exact movements, exaggerated movements, etc.)? 3. Does the individual appear lethargic? 4. Were questions answered in a logical manner? 5. Is their speech clear? Common Functional Limitations: Medical Aspects Notes 122 1. Psychological a. memory loss b. impaired judgment c. impaired decision making d. diminished psychomotor skills e. poor ability to handle stress/criticism f. poor concentration g. poor impulse control h. poor consistency 2. Intra-/interpersonal a. dependency b. anxiety c. isolation d. denial e. inaccurate view of themselves f. unrealistic in terms of aptitude, skills, and goals Vocational Impediment Connection: To determine an impediment assess, if there is a history of poor adaptation or adjustment in school, work, and personal relationships. In conjunction with a diagnosis of alcohol abuse/dependency, there should be a diagnosis of adjustment problems. Assess their work history and peer relationships on the job site. Explore reasons for job dismissal (e.g., attendance, punctuality, tolerance of authority, etc.). Assess the individual's functional and transportation needs in relation to vocational goals. Consider the individuals support system. Goal of Employment Considerations: Consider the individual's vocational interest past and present. Be specific with the individual in developing realistic vocational goals. Consider the individuals work personality (especially when it is a court ordered referral). Assess their participation in their rehabilitation process. Consider if they are in recovery and willing to maintain sobriety. Explore history and patterns of treatment and lengths of sobriety. IPE Considerations: 1. Be aware that test results may be invalid if tests were taken when actively using alcohol. 2. Dual diagnosis of mental illness (e.g., depression, personality disorder, etc.). 3. All issues that pertain to the client's responsibilities Medical Aspects Notes 123 need to be listed in the IPE (e.g., transportation, attendance at a support group, counseling appointments, and contact with the VR counselor). 4. Be alert for relapse. In some cases it is a part of the recovery process. 5. Consider specialized placement services to overcome poor work history. Medical Aspects Notes 124 DRUG ABUSE/DEPENDENCY Initial Interview Questions: 1. Is the individual alert and can he/she answer questions in an informative manner? 2. Can the individual relate history of onset of drug use to a certain event in his/her life? 3. Has the individual any physical involvements related to drug use (e.g., liver, stomach, heart, etc.)? 4. Has the individual undergone treatment? If so, what kind? Where? When? 5. Does the individual attend N.A. or any other support group? 6. Is the individual drug free (prescription and non- prescription). 7. Has the individual any legal problems? Observations During Initial Interview: 1. Does the individual seem agitated? 2. During the interview, does the individual seem euphoric, depressed, or present with a false affect? 3. Does the individual maintain good eye contact and seem invested in the interview process? 4. Ask them how each family member or friend has been affected by the person's drug abuse over a period of time? 5. Can the person engage in conversation in a logical sequence (relate one sentence to another)? 6. Does the person speak enthusiastically of the drug effects? Do they consider themselves more functional when using drugs? Common Functional Limitations: 1. Memory loss 2. Impaired judgment Medical Aspects Notes 125 3. Decision making 4. Handling stress/criticism 5. Dexterity 6. Concentration 7. Impulse control 8. Motor coordination 9. Consistency 10. Dependency 11. Anxiety 12. Isolation (rebellion against family, community, themselves) 13. Denial 14. Inaccurate self-concept 15. Unrealistic about aptitude and goals 16. Reaction to social pressure 17. Learned deviant behavior 18. Inability to relate things in a logical sequence 19. Inability to follow a daily routine 20. Mental confusion Vocational Impediment Connection: To determine an impediment assess, if there is a history of poor adaptation or adjustment in school, work, and personal relationships. In conjunction with a diagnosis of drug abuse/dependency, there should be a diagnosis of adjustment problems. Assess their work history and peer relationships on the job site. Explore reasons for job dismissal (e.g., attendance, punctuality, tolerance of authority, etc.). Limitations may include poor attention and concentration, memory impairment, reduced sensitivity to environmental stimuli (inability to recognize environmental change), loss of mechanical dexterity, and a disregard for potential dangers. Assess the individual's functional and transportation needs in relation to Medical Aspects Notes 126 vocational goals. Consider the individuals support system. Goal of Employment Considerations: Build on the client's educational and training strengths. Involve the family, family support can be crucial to rehabilitation gain. Assess job readiness based on general and specific employability such as social development, grooming, hygiene, relations to supervisors and co-workers. IPE Considerations: 1. If the client presents behavioral or psychiatric symptoms associated with the chemical dependency, this needs to be assessed before training or placement is initiated. The counselor should be cautious when the client insists on a quick job placement. 2. The client's responsibilities need to be realistic and clear when the IPE is written. The client needs to focus on his/her participation in each specific area of assessment, training, or direct placement and job retention practices. Medical Aspects Notes 127 EATING DISORDERS (Anorexia nervosa, Bulimia) Initial Interview Questions: 1. Have the individual clearly describe the eating disorder (e.g., how their eating pattern has caused them problems)? 2. How has their eating pattern affected their ability to work? 3. What sort of treatment have they had in the past or are they currently receiving? 4. Are they on any sort of medications and what are the affects? 5. Do they exercise? If so, have them describe what they do? 6. Do they have trouble sleeping? 7. Do they have trouble breathing or swallowing? 8. Do they have frequent headaches? 9. Do they at times feel confused or hallucinate? 10. Do they have any problems with alcohol or drugs (this is a commonly related addiction)? 11. Have they experienced any problems with strength or stamina? 12. Does the individual report stomach cramps or sore throats? 13. Does the individual have sores that do not heal? 14. Have they had any legal problems such as theft? Observations During Initial Interview? 1. Do they appear markedly underweight (this would be true for individuals with anorexia nervosa, in most cases individuals with bulimia tend to maintain average weight)? 2. Does the individual appear confused in any way? 3. Does there appear to be any obvious loss of physical strength or stamina? Medical Aspects Notes 128 4. Does the individual appear hyperactive or sleepy? 5. Do you notice thinness of scalp or hair? 6. Does the individual appear cold? 7. Does the individual appear angry or depressed? Common Functional Limitations: Bulimia or anorexia nervosa as disabling conditions in and of themselves normally pose little or no functional limitations after treatment. Often any limitations are the result of secondary conditions (e.g., compulsive disorders, depression, schizophrenia, or personality disorders). 1. Stamina 2. Strength 3. Decisions-judgment (frequently eating disorders are associated with impulse behavior such as alcohol/drug abuse, stealing/shoplifting and suicidal behavior). Vocational Impediment Connection: The key for eligibility for people with eating disorders is the determination of whether the medical condition causes or results in reasonably long lasting impediments to employment for the person. Many of the problems associated with eating disorders are acute medical problems only requiring medical services and outpatient therapy. Assess if the functional limitations associated with the disorder are long lasting or permanent once medical control has been gained and the individual's body weight has been normalized. Assess if there are underlying emotional or behavior problems which will effect the individual's ability to gain or maintain employment. Assess if there are associated secondary medical conditions or disabilities which are vocational limiting. Goal of Employment Considerations: Consider if the client will comply with any medical treatment prescribed. Treatment effectiveness is dependent upon keeping the medical regime in outpatient therapy (i.e., beyond hospitalization). Assess the individual's past history of treatment and results. IPE Considerations: 1. Medical stabilization should come first. Medical Aspects Notes 129 2. Client should follow treatment as prescribed through psychological examination. 3. Client should follow a regime of medications as prescribed. There is a belief that the recovery for eating disorders is the chemical dependency disease concept. With that in mind it would be strongly recommended that individuals with eating disorders routinely attend Overeaters Anonymous (OA). Medical Aspects Notes 130 OBESITY Obesity is a recognized medical condition from the excessive accumulation of body fat. A body weight 20% over that in standard height-weight tables is generally considered obesity. This is a physical disorder not generally associated with any distinct, psychological, or behavior syndrome. Most overweight people do not have any observable functional limitations resulting directly from the obesity. However, extremely overweight persons may have problems with physical stamina, have difficulties walking any distances and tire easily when performing light to medium work activities. Initial Interview Questions: 1. What is their weight and height? 2. How long have they been at their present weight? 3. How do they feel their weight has caused them problems past/current work, school, etc.? 4. What has been their experience with diets in the past? 5. Are they taking any medications and what are the effects? 6. Have they had any problems with breathing, high blood pressure, arthritis, leg pains, back pain, or any problems with their heart? 7. Have they had problems coldness/numbness in any extremities? 8. Have they had any other symptoms? 9. What do they feel keeps them from losing weight? Observations During Initial Interview: 1. Do they appear to have problems walking? 2. Do they appear out of breath after minor physical exertion? 3. Do they have problems with physical surroundings such as sitting on furniture, through doorways, or into vehicles? 4. Is there anything note worthy about their personal appearance? Common Functional Limitations: Medical Aspects Notes 131 1. Walking 2. Climbing 3. Balancing 4. Stooping 5. Kneeling 6. Crouching 7. Lifting 8. Dressing 9. Grooming 10. Stamina 11. Strength 12. Dependability Vocational Impediment Connection: Individuals with obesity may experience vocational impediments because their specific functional limitations may limit the jobs for which they can qualify. They may also need special job site accommodations such as specially made chairs. The may experience difficulty establishing appropriate social relationships with co-workers which can cause problems in job retention. Goal of Employment Considerations: Consider if they are willing to enter a behavior shaping weight loss program if necessary. Assess if the individual possesses enough strength and stamina currently to perform some jobs with appropriate VR services. Identify potential jobs where the limitations from obesity can be overcome through training or job placement. IPE Considerations: 1. Participation in effective weight loss program to include diet, exercise, and permanent change in eating habits. Medical Aspects Notes 132 2. Include supportive counseling. Effective weight loss programs take time (about six months to 50 lbs.) and it is difficult for most people to maintain motivation without regular supportive counseling. 3. Include adjustment counseling, if indicated, to include improving feelings of self-worth and improving relationships with co-workers. Medical Aspects Notes 133 AFFECTIVE DISORDERS (Depressive disorders: major depression, dysthymic disorder, adjustment disorders with depressed mood; Bipolar disorders: mixed, manic, depressed, and cyclothymic) Depressive Disorders: Most depressive episodes are functionally limiting. Acute depressive episodes have a good prognosis, with almost complete symptom relief and return to previous levels of family, social, and vocational functioning within about six months. About half of the persons who have a major acute depressive episode will have only a single episode. The other 50%, however, have a chronic or recurring pattern of depression. In roughly one-third of this group, the depression persists and they continue to experience persistent bodily complaints, irritability, sleep disturbances, fatigue, and pessimism along with depressed mood. These persons generally do not return to their previous levels of social functioning. The remaining two-thirds of the 50% discussed above have a recurring pattern of depression. Although they may return to previous levels of social and vocational functioning, this is disrupted by the recurrence of acute depressive episodes. Some persons with dysthymia may have a major episode of depression when stressed. Treatment usually brings a return to the dysthymic state. Prophylactic treatment with Lithium or tricylic antidepressants is effective in reducing rates of recurrence. The suicide rate among persons with chronic or recurrent depressions is about 30-35%. Adjustment disorder with depressed mood (reactive depression) is common in some cases where disabilities are caused by accidents or injuries where there is a sudden loss of function. Counseling that focuses on residual capacities and abilities reduces the consequences of loss effectively. Bipolar Disorders: Almost all persons with manic episodes also have depressed episodes. The first episode tends to occur in adulthood. Elational episodes have a high tendency to recur. However, the risk of recurrence can be reduced with Lithium and neuroleptics. During an elational episode, the person has distinctly impaired family, social, and vocational functioning. The person may appear head-strong, impulsive, manipulative, insensitive, and hostile toward others. Occasionally, the person's excitement becomes so severe that he or she is destructive of property, aggressive, and assaultive. Person with elational episodes tend to alienate family members and employers. There is a high Medical Aspects Notes 134 divorce rate. Initial Interview Questions: 1. Have the individual describe specifically the medications they take and any side effects. 2. How does the individual feel about taking medications? 3. How has the individual felt recently (e.g., sad, low, blue, etc.)? 4. Has the individual felt fatigue or lethargy? 5. Has the individual had any problems with loss of appetite? 6. Does the individual have any problems sleeping? 7. Does the individual have feelings of nervousness of feel agitated? 8. How does the individual think that other people feel about him/her? 9. Has the individual had any suicidal thoughts recently? 10. Does the individual do all that he or she plans to do each day? Observations During Initial Interview: 1. Does the individual look tired? 2. Was the individual able to concentrate? 3. Did the individual maintain eye contact? 4. Did the individual appear nervous (pacing, hand wringing, nail biting, finger tapping, etc.)? 5. Did the individual initiate conversation? 6. Did the individual appear energetic? 7. Are the individual's reports of self-esteem, capacities, and expectations realistic? Medical Aspects Notes 135 Common Functional Limitations: 1. Interpersonal skills (cooperation, tact, and assisting) 2. Dependability 3. Dealing with frequent changes 4. Stamina 5. Decision making 6. Strength 7. Judgment 8. Motivation or initiative 9. follow through or ability to follow instruction 10. Self-confidence/self-concept or image 11. Drowsiness from interrupted sleep patterns 12. Concentration 13. Memory 14. Stability and consistency of behavior Vocational Impediment Connection: The vocational impediment connection is made by linking the specific functional limitations for the individual to their ability to get or keep employment. Often individuals with depression or bipolar disorders have lost employment in the past due to the functional limitations they have demonstrated. Goal of Employment Considerations: Fully explore the individual's past history and results of any treatment. Consider the individual's willingness to adhere to a medication regime. Explore any secondary conditions as reactive depression is often secondary to spinal cord injury, traumatic brain injury, back injury, etc.. IPE Considerations: 1. Strict compliance with medications prescribed. Medical Aspects Notes 136 2. Arranging for a good general support system within the family or with the caregiver. 3. Involving the individual in support groups. 4. Cognitive behavioral therapy when recommended. 5. Selective job placement to include job-seeking-skills training, especially, interviewing practice. Follow -up on employment. 6. In bipolar disorders, there is usually a fairly predictable cycle of acute episodes (i.e., every 6 months, 12 months, etc.). Plan to provide additional support services prior to the episodes (not after), to sustain the person in planned services or employment. Medical Aspects Notes 137 DELUSIONAL (PARANOID) DISORDERS Delusional (paranoid) disorders are a group of disorders characterized by the delusion. A delusion is a false belief that the person maintains in the face of contradictory evidence. The belief is not bizarre. It involves situations that occur in real life. These include things like being followed, poisoned, being loved by someone famous, having a disease, being deceived by someone, etc.. Delusions are unique to the individual and are not shared by members of cultural or religious groups to which the person belongs. Delusion disorder replaces "paranoid disorder" to reflect the fact the delusions can involve things other than persecution. Six major types: persecution, jealousy, delusions of love, somatic delusions, grandiose, and unspecified. Initial Interview Questions: 1. How has the client's disorder specifically affected their ability to work in the past? 2. How does the client feel that this disorder affects their daily routine? 3. How does the client feel he/she gets along with others such as at a worksite? 4. What types of situations or work tasks does the client feel they should avoid on the job? Observations During the Initial Interview: 1. Does the client appear to be suspicious of the counselor's intentions? 2. Did the client freely share information or appear to withhold personal information? Common Functional Limitations: 1. Dependability 2. Conformance to rules 3. Judgement 4. Logical thinking Medical Aspects Notes 138 5. Cooperation 6. Tact Vocation Impediment Connection: Delusional disorders seldom result in a vocational impediment. The exceptions are situations where the object of the delusion is a boss or co-worker in the workplace. For example, the person who believes that he is being persecuted by his employer may quit or be fired because of it. Similarly, if delusions of jealousy involve a loved one or spouse who is also employed in the same setting, or the belief that one's co-workers are involved with the spouse or loved one, work difficulties may arise. Ordinarily, however, persons with paranoid delusions are suspicious and keep their secrets to themselves. Even when others become aware of their delusions, there is a tendency to view them as merely cranks. Much depends on the object of the delusion. The businessman who believes he is being persecuted by the IRS, or the co-worker who has a two timing spouse, is likely to be viewed with sympathy by others. Delusions often affect family and social relationships more than work related ones. Goal of Employment Considerations: Available research indicates that approximately half of the persons with delusional disorders experience a remission, and the other half have a chronic or persistent pattern. The prospects for treatment of those with chronic patterns is difficult at best. People with delusional disorders do not respond well to anti-psychotic medication. Individual psychotherapy is generally unsuccessful because the therapist cannot penetrate the elaborate, systematic, and logical construction of the delusion. Consequently, delusional thinking remains, and continues to motivate behavior. With treatment, the person with delusions may learn not to speak of them to others. However, he or she may engage in behavior that is consistent with delusional beliefs (e.g., shopping at night to avoid surveillance). IPE Considerations: Because individuals with delusional disorders have limited response to anti-psychotic medication and psychotherapy is generally unsuccessful, a vocational rehabilitation goal built around sensible and realistic goals that are consistent with delusional beliefs is most likely to be successful. Selective placement in work situations that do not arouse or intensify the delusions should be sought. Medical Aspects Notes 139 DEVELOPMENTAL DISABILITIES Developmental disabilities refers to below average intellectual functioning, with associated impairment in family, social or vocational functioning. Developmental disabilities have multiple causes. They can result form genetic defects (such as Down's Syndrome), maternal drug and alcohol use (Fetal Alcohol Syndrome, mother's using crack cocaine), maternal infections (German measles), and a variety of other causes. Most developmental disabilities do not have a clear causative factor. Developmental disabilities are diagnosed primarily on the basis of intelligence. However, persons with developmental disabilities frequently manifest other brain dysfunctions beyond limited intelligence and diminished learning ability. Attentional deficits, distractibility, perceptual difficulties, reduced coordination, poor dexterity, slow rate of performance, and motor problems frequently occur. These have definite vocational implications. Initial Interview Questions: Whenever possible, the interview questions should be posed directly to the individual with the developmental disability as opposed to a family member or caregiver. Interviewing can be a challenge because of speech difficulties and impaired thought content that is associated with limited intelligence. At the same time, however, most people with developmental disabilities are quite capable of producing yes-no and like-don't-like responses to specific questions. Thus, direct questions as opposed to open-ended questions are preferred in interviewing. Be aware, however, that persons with developmental disabilities often produce what they think are socially desirable responses, rather than stating their own views. Counter-balancing specific questions or stating questions in a socially undesirable form avoids thin. For example, "Would you like to go to work?" can be counterbalanced with "Would you like to stay at home?" Persons with developmental disabilities are more concrete thinkers. They may be able to respond to a question asked concretely (i.e., did you like Mr. Smith?), but not the same question asked more abstractly (i.e, did you get along with your boss?). Use short questions or sentences, rephrase them when needed, and allow for non-verbal responses when interviewing. 1. Who do you live with? Who helps you do things? 2. If the individual has held jobs in the past, what has the employer told the individual about their work? 3. How does the individual feel he/she gets along with others Medical Aspects Notes 140 (specifically spell out support individuals)? 4. Are they taking any medications and how do the medications affect them? 5. Have they had seizures? 6. Can they operate a motor vehicle, and do the have a valid driver's license? Observations During Initial Interview: Interview observations should focus on the person's social skills and social behavior, particularly in relationship to age appropriate behavioral standards. Relevant observations include the following: 1. Is the individual's dress and grooming appropriate? 2. Does the individual exhibit mannerisms (i.e., fidgeting, wandering around, interrupting, making noises, talking in a loud voice, etc.)? 3. Does the individual exhibit dependency such as deferring to a parent or others to answer questions? 4. Is their speech understandable? Is the content appropriate? Can they start and maintain a conversation? 5. Did they have difficulty with memory (e.g., addresses, work history contacts, etc.)? 6. Did they seem oriented as to time and place? 7. Did they exhibit difficulties with motor coordination? Common Functional Limitations: 1. Learning work skills 2. Self-direction 3. Communication 4. Interpersonal skills 5. Work tolerance 6. Mobility Medical Aspects Notes 141 7. Self-care 8. Transportation (the ability to drive a motor vehicle or make use of public transportation). Vocational Impediment Connection: Determining the vocational impediment to employment is usually not an issue with persons with developmental disabilities. There is a clear relationship between the common functional limitations with developmental disabilities and abilities to prepare for, enter, and maintain employment. People with developmental disabilities may exhibit inappropriate behaviors, be unable to operate motor vehicles, or make use of public transportation, and may be unable to complete employment applications and interviews appropriately. All of the latter create vocational barriers. Goal of Employment Considerations: Consider parental expectations regarding the person with a developmental disability. Unfavorable parental expectations toward employment are a leading cause of VR program failure. The consequences of competitive gainful employment must be thoroughly explored with parents before making an eligibility decision. The role of parents and other relatives as a long-term support system must also be explored, along with the availability of an alternative support system to replace the parents if necessary. IPE Considerations: 1. Selective job placement which will require intervention by staff with employers. 2. Making arrangements to deal with transportation problems. 3. Assuring that long term support is in place to include residential, self-care, financial, recreational, etc.. 4. Provision of training, if necessary, to correct inappropriate work behavior. 5. Provision of vocational training to develop specific work skills. 6. Post-placement services to deal with initial needs for increased supervision. Medical Aspects Notes 142 PERSONALITY DISORDERS (Paranoid, Schizoid, Schizotypal, Histronic, Narcissistic, Antisocial, Borderline, Avoidant, Dependent, Obsessive compulsive, Passive aggressive) Personality disorders are a group of disorders characterized by disruptions in basic personality traits. Personality disorders are diagnosed only when personality traits become so prominent and rigid as to cause social dysfunction. That is, a personality trait or characteristic is accented to a degree that the person's personality style is disturbing or offensive to others. It is important to recognize that anyone's personality style can be described in terms of basic personality traits. The diagnosis of personality disorder, however, should be made only when there is clear evidence that the attitudes and behaviors resulting from the trait exceed ordinary social and cultural expectations and demands to the degree that they are unacceptable to others. Initial Interview Questions: 1. How does the individual feel their disorder has specifically affected work they have done in the past? 2. How does the individual feel he/she gets along with others in work environments or other situations? 3. How does the individual think that other people view him/her? 4. Does the individual often feel irritable, frustrated, or angry? 5. How has the individual responded or adapted to on-the-job changes in the past (change of supervisors, co-workers, production demands, work methods, etc.)? Observations During Initial Interview: 1. Was there any evidence of illogical thinking such as bizarre references, suspiciousness, paranoia, delusions, etc.? 2. Was the individual appropriately attired? 3. Did the individual show any signs of irritability, frustration, or anger during interview? 4. Were any threats made or did it appear the individual had Medical Aspects Notes 143 thought of harming others? 5. Did the individual seek assurance? 6. Did the individual try to give an unrealistic, positive picture of self and capabilities? Common Functional Limitations: 1. Cooperation 2. Tact 3. Dependability 4. Judgment 5. Logical thinking 6. Dependency on others 7. Impulse control 8. Distractibility 9. Tolerance to frustration 10. Respect for people or property 11. Proper dress/attire 12. Adaptability to change Vocational Impediment Connection: Individuals with substantial personality disorders generally report many difficulties in past work experiences. It is usually not difficult to show a connection between the deficits caused by a personality disorder and an individual's ability to maintain employment. Goal of Employment Considerations: Conventional methods of behavior adaptation such as work adjustment counseling, psychosocial counseling, etc. are normally ineffective in altering, maladaptive behavior in individuals with personality disorders. In addition, medications have not been shown to be effective. Therefore, consider finding a job where the individual's behavior can be accommodated. Medical Aspects Notes 144 IPE Considerations: 1. Selective job placement. The specific type of job or work environment should be located wherein the individual's behavior deficits can be accommodated. 2. Intervention between client and employer during the first few months of employment to insure communication and adjustment (job coach). Medical Aspects Notes 145 SCHIZOPHRENIC DISORDERS (Schizophrenic disorders: Disorganized, Catatonic, Paranoid, Undifferentiated, Residual) The schizophrenic disorders are a group of psychotic conditions that cause massive disruptions of perception, cognition, emotion, and behavior. Schizophrenic disorders usually onset in late adolescence and early adulthood (usually before age 25). Long term follow-up studies indicate that persons who have an initial acute schizophrenic episode fall into one of three groups: 1. Full recovery. About 20-25% of those who develop schizophrenia fully recover. They remain free of psychotic symptoms and return to normal levels of social and vocational functioning. 2. Mild effects. About 20-25% have mild residual effects. They continue to have hallucinations and delusions, but have relatively normal observable behavior with only mild impairment in social and vocational functioning. 3. Moderate to severe. About 40-60% have moderate to severe outcomes. They continue to have marked schizophrenic symptoms, abnormal observable behavior, and are severely impaired in most areas of social and vocational functioning. As a group, only about 35% of persons with schizophrenia who do not fully recover engage in productive vocational activity. Although there is no known cure for schizophrenia, several modes of treatment can reduce the impact of schizophrenic disorders on the person. Neuroleptic medication is effective in the treatment of acute schizophrenia. It also appears effective in preventing future psychotic relapses in schizophrenic persons in remission. However, medication compliance is often an issue because of side effects. Also, in paranoid schizophrenia, the nature of the disorder generally interferes with medication compliance unless the person is closely supervised. Behavior therapy is effective in the treatment of schizophrenic disorders. Operant techniques, such as token economies, are effectively implemented in in-patient, day hospital, and half-way settings where staff can control the reinforcers. These techniques are particularly effective in reducing aggressive behaviors and increasing self-maintenance behaviors. However, they are not effective in developing interactive social behavior. Response acquisition procedures, including social skills Medical Aspects Notes 146 training, are effective in developing interactive social behaviors. These include such things as starting a conversation, self-disclosure, listening skills, giving and receiving criticism, and assertion. Response acquisition techniques can also be applied to a variety of daily living skills. Behavioral family therapy is effective in improving family functioning, reducing stress on the person, and involving family members to participate actively in community management of the disorder. Behavioral family therapy typically has three components: education, communication, and problem solving. Counseling and psychotherapy are not effective treatments for people with schizophrenia. However, there is indication that an effective interpersonal relationship with a counselor or case manager is necessary for the success of other treatments. A supportive working relationship with the person can maintain compliance with drug treatment and motivation for behavior therapy. Stress inoculation training and relaxation training are useful in teaching the person how to effectively cope with stressful life events. The role of stress induced relapse and decompensation is controversial. There is no research support for the hypothesis that life events are associated with the onset of illness. However, people with schizophrenia who do relapse tend to have more stressful life events than those who do not. There is no clear pattern of stressful events among people with schizophrenia. Initial Interview Questions: Persons with schizophrenia are a very heterogenous group. Each person has a unique configuration of assets and limitations that must be identified for vocational rehabilitation purposes. Schizophrenia is a pervasive disorder in that it affects all major life functioning (although to different degrees in each individual case). Consequently, the diagnostic interview must go into all major areas of life functioning: personal, family, social, community, educational, and vocational. The presence of negative symptoms, including poverty of thought and diminished emotional responsiveness, make it difficult to establish an effective counseling relationship and to gather meaningful information in a single interview. Persons with schizophrenia generally have difficulties providing full and complete responses to broad, open-ended questions. For example, usually it is unproductive to ask the person with schizophrenia to describe his or her vocational impediment. A more effective approach is to ask whether or not he or she has a problem with specific vocational behavior (e.g., going to work on time, going to work everyday, producing enough work, following the boss's orders, etc.). Medical Aspects Notes 147 An effective diagnostic interviewing strategy with the person with schizophrenia is to use two or three interviews, each of which gets increasingly focused and detailed. For example, the first interview would focus on the heterogeneity of and pervasiveness issues. This interview range broadly over the person's life circumstances (personal, family, community, etc.). The intent is to identify areas of functioning that are impacted by the schizophrenia. The second interview goes into more depth on strengths and weaknesses in those areas of life functioning that are impacted by the illness. The third interview (if needed) goes into detail on very specific vocational assets and impediments. The active symptoms of the disorder, particularly the hallucinations and delusions, are the focus of most psychiatric and mental health treatment. Consequently, the person with schizophrenia often comes to VR with the expectation that the counselor will want him or her to talk about those active symptoms. The presence of active symptoms, however is not very predictive of vocational rehabilitation success unless these intrude into the person's ordinary social interactions with others. In other words, active symptoms are not a problem unless the person calls the attention of others to them. A useful rule of thumb for the counselor is to avoid directly going into the active symptomology and to keep the interview focused on discussions of functioning in various life situations. If the person voluntarily begins to describe active symptoms, and the expectation that this is what the counselor wants to hear about, the person can be reminded to discuss them with his or her psychiatrist, psychologist, or mental health worker, and attention can be refocused on functional activity. In this way, the counselor can focus the person's attention on what is relevant for VR proposes and also set the stage for observing the extent to which active symptoms intrude into ordinary conversation and dealings with others. 1. Does the individual feel that they are able to work given their current condition? 2. How does the individual think their condition will interfere with future work? Observations During Initial Interview: 1. Perceptual symptoms. Did the individual exhibit auditory, visual, or other hallucinations? Report other types of perceptual disturbances (lights looking brighter or dimmer, people seeming larger or smaller, objects seeming closer or further away, time passing too slow or too rapid)? Medical Aspects Notes 148 2. Cognition. Did the individual exhibit: lack of speech? Vague speech content? Increased response latency? Blocking on thoughts? Did the individual exhibit delusions (false beliefs such as believing one or more individuals or organizations are trying to harm him or her; punishment for some misdeed; spouse or lover is unfaithful; something abnormal is happening to the body; unrealistic beliefs about his or her talents or accomplishments; religious or spiritual themes; being controlled by others, etc.)? 3. Emotional responses. Did the individual exhibit flat, blunted, or inappropriate affect (such as a lack of vocal inflections, lack of expressive gestures, poor eye contact, unchanging facial expression, lack of interest in ordinary daily activities, etc.)? 4. Motor Functions. Did the individual exhibit slowed motor responses, poor quality of movement, slurred speech? 5. Behavior. Did the individual exhibit poor grooming and hygiene? Inability to concentrate, pay attention, or persist on task? Isolation and withdrawal from social activities? 6. Drug side effects. Does the person show or report side effects associated with neuroleptic medication including: feeling tired; low blood pressure; dry mouth; blurred vision; racing heart; loss of sexual interest or impotence; muscle spasms; rocking back and forth; pacing; tremors; uncontrollable movements of the mouth, lips, or tongue? Common Functional Limitations: 1. Interpersonal skills (cooperation), tact, and assisting 2. Self direction (dependability, decision making, difficulty with frequent change) 3. Stamina 4. Understanding instructions (particularly if these involve abstract thinking such as underlying principles, reasoning, etc.)? Medical Aspects Notes 149 5. Motor coordination 6. Eye-hand-foot coordination 7. Form perception 8. Spatial perception 9. Memory 10. Problem solving 11. Flexibility and adapting to change Vocational Impediment Connection: Most of the functional limitations described above, either alone or in combination with others constitute a substantial impediment to employment. Consequently, establishing a presence of a vocational impediment is usually not an issue. People with schizophrenia commonly lead isolated and sedentary lives. The are deconditioned and lack stamina to get through an eight hour day and the strength to perform some types of work. Problems in learning new jobs and understanding instructions play a major part in determining vocational impediment. People with schizophrenia often have difficulty understanding, reasoning, and making judgments by applying retained instructions, procedures, or rules. They often lack the logic necessary to deal with specific situations and events encountered on the job. People with schizophrenia have difficulty communicating with others because of delusions and hallucinations which intrude into ordinary conversation. They may also have a blunted emotional response making it difficult for others to comprehend what the individual is trying to communicate. A variety of drug side effects may also impair motor functioning including walking, climbing, balancing, etc. Goal of Employment Considerations: 1. Participation in and compliance with medical management program. Continuing medical management of schizophrenia using neuroleptic medications is essential. Although some people with schizophrenia can maintain without drug therapy, this should be done only under medical supervision. Additionally, as the individual gets involved in an active vocational rehabilitation program, his or her medication needs may change. Medical Aspects Notes 150 2. Stable social support, living situation, and finances. The presence of strong family support, a stable living situation, and an income adequate to meet basic needs (either from family or an income maintenance program) is essential for vocational rehabilitation success. In the absence of these, VR plans break down because a person's basic needs for food, clothing, shelter, security are met. 3. Availability of services necessary to overcome each specific vocational impediment and employment barrier. Successful vocational rehabilitation depends on overcoming all of the person's identified impediments to employment not just a select few. IPE Considerations: Active involvement of the individual in the development of the IPE is essential for assuring long term compliance and involvement in the VR plan. If the individual does not fully agree with the IPE goals, objectives, and specific services, there is a high risk that he or she will fail to cooperate or drop out of VR services. The plan must be based on a thorough and detailed identification of specific vocational impediments and employment barriers. As noted in the description of the disability, effective treatments are based on operant conditioning, behavior management, and intensive instruction methods. These methods are useful when applied to specific skill and behavior problems. Positive results are usually achieved in short periods of time (one month or less) when specific interventions are used to correct specific skill or behavior deficits. This provides the individual with evidence of positive changes and progress. It also provides the counselor with frequent opportunities to reinforce participation in the IPE. Overall plan duration is determined by the number of skills and behaviors that need to be changed to reduce or remove the client's vocational impediments. Since schizophrenia is cyclical or episodic in nature, the client's interepisode interval (the period of time between major psychotic episodes) is a major factor in planned development. The entire plan (including time needed for job placement and follow-up) must fit within the client's interepisode interval if the client is to be successfully rehabilitated. Medical Aspects Notes 151 SPECIFIC LEARNING DISABILITIES Assessment: 1. Difficulties in school topics such as : arithmetic, reading, etc. or in some cases specific study style may come up in terms of managing time, taking notes, benefiting from teacher feedback and in interpersonal relationships with other students, family, etc.. There are three specific areas of information that must be analyzed and synthesized on which decisions are based. The first is client history, which includes school records, family history, etc. The second is behavioral observations on the part of the counselor and other professional staff such as teachers, counselors, and supervisors. The third is objective diagnostic testing, which would include school psychological reports, vocational evaluations, and psychological evaluations. The client history should include as a minimum an interview with the client and significant other family members to elicit: 1) personal data, 2) physical/medical history, 3) social information, 4) special interests and activities, 5) emotional coping abilities/problems, 6) educational background, 7) vocational history and expressed interests. 2. Educational and School Records a. Schools and program attendance b. Grades received c. Behavioral and/or social/emotional problems noted d. Achievement and other testing results e. Sensory problems f. Interpersonal social relationship styles g. Involvement in remedial or special education services Interview may reflect resistance to attend school, poor grades, frequent absenteeism, fights, withdrawal, frequent and unspecified illnesses. 3. Objective Assessment: a. Information elicited or gathered from psychologists (school, clinical, and neuropsychologist). b. Physicians c. Allied health personnel such as social workers, speech therapists, etc. 4. Data may come from general medical exams, special neurological exams, psychological exams, neuropsychological exams or situational assessment. Medical Aspects Notes 152 Initial Interview Questions: 1. How does the client describe his/her specific learning disability? What specific areas does it affect (e.g., concentration, note taking, memory, decision making, reasoning, reading, spelling, math, following instructions)? 2. How do they regard their school experience and how do they consider their adjustment both at school and home? 3. What are their vocational goals and how do they see the specific disability affecting them? 4. Have they had any work experience, and what degree of success have they experienced, and what difficulties have they faced? 5. What special strengths do the bring to accommodate or compensate for the specific learning disability? What are they good at? 6. How do the feel about themselves? (Often people with specific learning disabilities have low self-concept). 7. How do they get along with others? 8. How effectively does the client communicate with others verbally? Nonverbally? Observations During Initial Interview: 1. How is the client's self-image projected nonverbally? 2. How is his/her eye contact? 3. Was his/her behavior appropriate? 4. How accurately did the client complete necessary forms? 5. Did the client understand items they were asked to read and how long did it take? 6. Did there appear to be any problems with memory? 7. Was he/she agitated or easily distracted? Medical Aspects Notes 153 8. Did the client use aids (such as a list of doctors, employers)? Common Functional Limitations: 1. Ability to organize work 2. Time management problems 3. Conceptualization problems 4. Decision making problems 5. Maturity 6. Reading, writing, and spelling 7. Math calculations 8. Auditory/visual memory 9. Form and spatial perception 10. Concentration 11. Attention to task 12. Visual motor problems 13. Abstract thinking 14. Following instructions 15. Self image 16. Interpersonal relations 17. Impulse control 18. Unclear/vague communication style 19. Inability to focus on details 20. Sequencing problems 21. Relational distortions Vocational Impediment Connection: Medical Aspects Notes 154 Learning disabilities restrict the range of work a person can do effectively and efficiently. Often the client needs help in understanding the impact of his/her limitations in order to make appropriate vocational choices/decisions. Individual with learning disabilities are many time limited in the jobs that are available to them. In additional they may need special assistance to be able to handle all the job duties of those jobs they can perform. Their skill deficits obviously limit their performance in certain jobs, but the counselor can also show general functional limitations that would apply to any job they undertake. These might include: organizational skills, self image, relationships with others, concentration, attending to task, following instructions, etc.. Another way to show a vocational impediment is to show the potential of the individual and assess how achieving that potential will be very difficult without special assistance. An individual may have the potential to achieve a vocation requiring a bachelors degree but needs special assistance to achieve the degree. Goal of Employment Considerations: The individual and family are important considerations. Often the individuals in high school are referred and carry with them the expectations for goals which may not be feasible. This needs to be assessed so that an achievable outcome is agreed upon by all involved. It must also be remembered, however, that they may have capabilities that can be maximized through learning alternative techniques or ways of accomplishing tasks. IPE Considerations: 1. Client or family expectations, if unrealistic, must be dealt with through counseling. 2. If the individual has low self esteem the counselor needs to arrange for successes, even if small. 3. Focus on accommodation strategies vs. school-based remediation strategies. Learn alternative means of accomplishing vocational goals. Use of work aids/school aids (e.g., tape recorders, calculators, check lists, calendaring, time scheduling. 4. Reality counseling and honest feedback. Medical Aspects Notes 155 5. Provision of aids such as glasses or hearing aids to maximize use of those senses. 8. Selective job placement. Arrangements for accommodations at the job site to help the client best learn tasks (e.g., verbal versus written instruction, aids such as time schedules, check lists, etc.). Find ways to accommodate or circumvent deficits and reduce distractions. Promote realistic goals and choices of work setting/demands. 9. ….. Medical Aspects Notes 156 CASP 532 Medical/Physical Aspects of Disability by Dr. Jerry Fischer, CRC, LPC Medical Terminology Rules 1. Medical terminology is generally broken down into three parts a) a prefix (the word beginning; b) root word (the foundation word, what the word is all about); and c) a suffix ( the word ending). 2. Often the three word parts are connected with a combining vowel (such as "o" usually), to make the word sound more aesthetically pleasing. The combining vowel can connect a root word to a root word, or a root word to a suffix, or a prefix and a root word. combining vowel = o esophag o gastr o duoden o scopy root root root suffix esophagogastroduodenoscopy 3. Defining medical terms: a) define the suffix first, and b) go back to the front of the word. esophagogastroduodenoscopy: define scopy first = a visual examination. All together this word would be defined as follows: a visual examination of the esophagus (food tube), stomach and small intestine. 4. Exceptions to combining vowels a) when you have suffix beginning with a vowel do NOT use a combining vowel to connect them. When combining "gastr" (stomach) to the suffix "ic" (pertaining to) do not use a combining vowel( such as "o"). The correct combination would be gastric. NOT gastroic. 5. Singular and plural forms: a singular noun that ends in "um" to change to plural drop the "um" and add "a": "um" > "a". Diverticulum (singular) > diverticula (plural). A singular noun that ends in "us" becomes a plural by adding "i". Calculus (singular) > caluculi (plural). A singular noun that ends in "is" becomes plural by adding "es". Metastasis (singular) > metastases (plural). A singular noun that ends in "ix" or "ex" becomes plural by adding "ices". Apex (singular) > apices (plural). A singular noun that ends in "a" becomes plural by adding "e". Vertabra (singular) > vertabrae (plural). 6. Some suffixes decribe words as they become nouns or adjectives. The noun suffixes "um" and "ium" meaning tissue or structure. The noun suffixes "ule" and "ole" meaning small or little. Medical Aspects Notes 157 MEDICAL TERMINOLOGY PREFIXES Prefix Meaning Example a, an- without, lack of ablepharia ab- from, off, away from abnormal ad- to or toward, addition to adrenal nearness or intensification ambi- bothsides ambidexterity ana-, an- upward, backward, excessive anatropia or again ante- before in time or place antenatal antero- before anterosuperior anti-, ant- against or over against antibiotic apo-, ap- from, separation apophysis bi-, di two or twice bimaxillary circum- around circumanal co-, con,- together, with coarticulation com- contra- against, opposed contrastimulant de- down, away from dehydration dia- through between, diagnosis across, apart or completely dis- reversal or separation displacement duplication e-, ex- away from, without, exogenous or outside (sometimes denotes completely) ecto- situated on; without or ectoderm on the outside Medical Aspects Notes 158 em-, en- in encephalopathy endo-, end- inward situation, within endonasal ep-, epi- on, upon, or over epidural extra- outside, beyond, in additon to extrathoracic hemi-, semi- one-half hemiparesis demi- hyper- above, beyond, or excessive hyperplasia hypo- beneath, under, or deficient hypoglycemia in-, im- in, within, or into; not immature infra- situated, formed, or occuring infraclavicular beneath inter- situated, formed or occuring intercostal between intra- situated, formed, or occuring intracerebral withing meso- situated in the middle or mesoretina intermediate meta- beyond, change, exchange, or metamorphosis transformation milli- unit of measurement (one one- millicurie thousandth) pan- all pansinusitis para- beside, beyond, accessory to, parauethral apart from, against per- throughout space or time percutaneous peri- around peribronchial post- after or behind postocular pre- before preoral Medical Aspects Notes 159 pro- before or in front of prognosis quadri- four or fourfold quadrilateral re- back, again, contrary reflex retro- backward or located behind retrocervical sub- under, near, almost, or subpulmonary moderately super- above or implying excess supercilia supra- above or over suprasternal sym-, syn- together, with, union synonychia ter-, tri- three or threefold tribrachia trans- through or across, or beyond transduodenal ultra- excess or beyond ultraviolet uni- one unilobar Medical Aspects Notes 160 MEDICAL TERMINOLOGY SUFFIXES Suffix Meaning Example -algia,-dynia painful condition cephalgia -cele tumor, swelling or hernia hydrocele -cyte cell erythrocyte -ectasis expansion or dilation broniectasis -genic producing or productive bronchiogenic -gram that which is written or pneumogram or recorded -graphy act of writing or recording cardiography or a method of -iasis a process or condition resulting cholethiasis therefrom, particularly a morbid condition -itis inflammation mastoiditis -ology science or study of pathology -morphy form or shape polymorphic -iod resemblance to the thing lymphoid specifiecd -oma tumor or neoplasm adenoma -osis abnormal increase, condition, hematonephrosis or disease process -pathy a morbid condition or disease myopathy -penia abnormal reduction in number of leukocytopenia -phagia, perversion of appetite, or a aerophagy -phagy relationship to eating or swallowing -phobia abnormal or morbid fear of/or photophobia aversion to Medical Aspects Notes 161 -phoresis transmission of electorphoresis -plegia paralysis or stroke quadriplegia -pnea breathing apnea -poiesis formation hematopoiesis -ptosis downward displacement nephroptosis -rrhage excessive flow menorrhagia -rrhagia -rrhea flow or discharge pyorrhea -stasis maintenance of (or hemostasis maintaining) a constant level; preventing increases by multiplication -staxis hemmorrhage gastrostaxis -trophic nutrition,; nourish hypertrophic -uria urine polyuria -centesis perforation or tapping thoracocentesis -desis binding or fusion arthrodesis -ectomy excision of structure or ileectomy organ -lithotomy incision of a duct or organ uretero- for removal of a stone lithotomy -lysis dissolution, breaking down myolysis -ostomy operation in which an gastroduoden- artificial opening is formed ostomy -otomy incision or cutting osteotomy -pexy fixation mastopexy -plasty surgical (plastic) repair perineoplasty -(r)rhaphy suture blepharorraphy Medical Aspects Notes 162 -scope instrument for examination laryngoscope -scopy act of examination cyctoscopy -tripsy crushing lithotripsy Medical Aspects Notes 163 MEDICAL TERMINOLOGY ROOTS Body as a Whole Root Meaning Example celi abdomen celiotomy cephal, head cephalocele cephalo cheiro, chir hand cheirospasm dactyl, digit (finger, toe) dactylogram dactylo lapar, laparo loin or flank; abdomen laparomyitis ped, pes, foot pedal pedo psych mind psychosis thorac, chest thoraco- thoraco myodynia trachel neck or neck-like structure trachelorrhaphy trachelo viscer organs of the body viscero- viscero peritoneal Dermatologic Root Meaning Example bucco cheek buccolabial cheil, chil lip cheilorrhaphy derm, derma skin dermatitis dermat,dermato, dermo fibro fibers fibroplasia hist tissue histokinesis kerato horny keratoderma Medical Aspects Notes 164 labi, labio lip labiomycosis mast, masto- breast mastoptosis mammo onych, onycho nails onychotomy pilo hair piloerection sarc- flesh sarcomatous Musculoskeletal Root Meaning Example arthr, arthro joints arthritis chondr, cartilage chondrosis chondri, chondrio, chondro cleid, cleido clavicle cleidocostal cost, costo ribs costophrenic crani, cranio skull or cranium craniosclerosis gnath, gnatho jaw gnathoplasty ili ilium iliolumbar my, myo muscle myotasis osteo bone osteodystrophy phren, phreno diaphragm phrenocolic rachi, rachio spine rachioscloiosis sacro sacrum sacrococcyx spondyl vertebra sponylosis spondylo ten, tendo tendon tenotomyotomy teno, tenonto Medical Aspects Notes 165 Respiratory Root Meaning Example bronch, bronchus bronchoplegia broncho laryng, larynx laryngorrhaphy laryngo pleur, pleura pleuracentesis pleuro pneum, air, gas, respiration pneumohemo- pneuma, thorax pneumato, pneumo pulm, pulmo lungs pulmonic rhin, naso nose rhinalgia tracheo trachea traceobronho- scopy Circulatory Root Meaning Example angio vessel, usually a blood vessel angiopathy angi arterio artery, arteries arteriolith cardi, cardia heart cardiology cardio phleb, phlebo vein or veins phlebotomy pyle portal vein pylethrombosis thrombo clot or thrombus thrombo- thrombus phlebitis vas, vaso vessel or duct vasotonia ven, veno vein venostasis Medical Aspects Notes 166 Hemic and Lymphatic Root Meaning Example aden gland or glands adenoid hem, hema blood hematocytopenia hemata, hemato, hemo lien, lieno spleen lienorenal lymph lymph lymphocytosis lympho plasm plasma or substance of a cell plasmoma plasmo splen, spleno spleen splenectomy Digestive Root Meaning Example dent, denta teeth dentiparous denti, dento, odont, odonto enter, entero intestive enterocleisis gastr, gastro stomach gastrectasis gingiv, gums gingivo- gingivo glossitis hepat, hepto liver hepatitis ile, ileo ileum ileocec- ostomy linguo, gloss tongue linguodental or, oro, os mouth orolingual pharyng pharynx pharyngo- pharyngo stenosis proct, procto rectum proctectasia Medical Aspects Notes 167 pyloro pylorous pylorostenosis sial, sialo saliva sialoaerophagia stoma mouth stomatoplasty Urogenital Root Meaning Example balano glans penis or glans clitoris balanoplasty colpo vagina colpopexy cyst, cysti bladder, sac cystoscopy cysto, cystido episio vulva episoperineo- plasty hyster, metr uterus hysteropexy nephr, kidney nephrosclerosis nephero, ren oophor, ovary oophoro- oophoro salpingectomy orchi, testes orchidalgia orchido, orchio pyel, pyelo pelvis of the kidney pyelonephrosis salpingo uterine tube salpingoplasty ur, uro urine, the urinary tract urologist urono ureter ureter ureterectomy uretero urethro urethra urethrostenosis Endocrine Root Meaning Example Medical Aspects Notes 168 adreno adrenal glands andrenomegaly thyro thyroid thryocele Nervous Root Meaning Example encephal brain encephalo- encephalo malacia mening brain and/or spinal column meningorrhagia myel, myelo marrow, especially in relation myelocele spinal cord neur, neuro nerves neuroplasty Eye and Ear Root Meaning Example blephar eyelid or eyelash blepharal core, pupil of the eye corelysis coreo irid, irdo iris of the eye or colored circle irdoplegia kerato cornea keratohemia oculo eye oculomotor ophthalm eye ophthalmoscopy ophthalmo ot, oto ear otopharyngal phaco crystalline lens phacomalacia Medical Aspects Notes 169 Descriptive Terms Root Meaning Example acro extremity acrodermatitis actino ray, radiation actinotherapy atelo imperfect, incomplete atelectasis bio life biology brachy short brachygnathia brady slow bradypnea carcin carcinoma carcinogenic carcino chlor, green chloroma chloro cryo cold cryotherapy crypto hidden, concealed cryptorchidism cyt, cyto cell cytopenia dextro right dextrocardia dys painful, difficult, abnormal dystrophy electro relating to electricity electro- cardiograph esthesio feeling anesthesia eu well, easily, good eukinesia gero, geronto old age, aged gerontologist glio gluey substance glioma homo same homograft hydr, hydro water hydroperi- toneum idio self, one's self idiogenesis Medical Aspects Notes 170 latero side lateroflexion leio smooth leiodermia lyso dissolution lysogenesis macro large macrocephaly malaco abnormal softness myelomalacia mega, megalo great megalosplenia micr, micro small microophthalmia mono one, single monocular morpho form morphology multi, poly many, much multilobar myco fungus mycosis narco stupor narcotic necro death necrophobia neo new, strange neoplasm oligo few, little, scanty oligodipsia pachy thick pachyderma phon, phono sound, often used with voice phonomyogram photo light photosensitive platy broad, flat platyspondylia pleo more pleomastia postero behind posterolateral pseud, false pseudocirrhosis pseudo pyo pus pyometra radio ray, radiation radiotherapy Medical Aspects Notes 171 rhabdo rod-shaped rhabdiod scirrho hard cancer, scirrhous scirrhoma carcinoma sinistro left side sinistrocardia spheno wedge, wedgeshaped sphenoparietal staphyl, bunch of grapes, used to denote staphyloplasty satphylo relationship to uvula or to staphylococci steno narrowing stenothorax tachy swift tachyphrenia vesci, vescio bladder, blister vesciovagino- rectal xanthro yellow xanthrochromia Medical Aspects Notes 172 CHARTING ABBREVIATIONS Ab = Abortion ba = Barium ABD, Abd = Abdomen BBB = Bundle branch block ABG = Aterial Blood Gases B.B.S. = Bilateral breath sounds AC = Acromioclaviular BCP = Birth control pill ac = Before meals (antecibum) BID = Twice a day Acel = Acceleration BIH = Bilatera Inguinal Hernia ACIOL = Anterior Chamber bil = Bilateral Intraocular Lens Bili = Bilirubin ADA = American Diabetic Association BK = Below knee Ad lib = In accordance with ones BKA = Below the Knee Amputation wishes BM = Bowel movement AF, Afb – Atrial fibrillation BOW = Bag of waters A/g= Albumin globulin ration BP, B/P = Blood pressure AGA = Average gestational age BPH = Benign prostatic hypertrophy AIDS = Acquired Immunological BPM = Beats per minute Disease Syndrome Brady = Bradycardia Aj = Ankle Jerk Br = Breech AK = Above Knee BR = Bed rest ada = Also known as BRP = Bathroom privileges ADA = Above the Knee Amputation Brsts = Breasts ALS = Amiotrophic lateral sclerosis BSC = Bedside commode AMA = Against medical advice B.S. = Blood sugar amb = ambulate BSO = Bilateral Salpingo— AMI = Acute myocardial infarction oophorectomy Aminio – Anmiocentesis BTB = Beat to Beat amp = Ampule BTBV = Beat to Beat Variability amt = amount BTL = Bilateral Tubal Ligation ANA = antinuclear body Btl = Bottle ant = Anterior BUM = Blood Urea Nitrogen AODM = Adult onset diabetes Bx = Biopsy mellitus a/o = alert and oriented C = Cervical Ap = Apical CA = Carcinoma AP = Anterior psterior Ca = Calcium ARDS = Adult respiratory distress CABG = Coronary Artery Bypass Graft syndrome CAD = Coronary artery disease AROM = Artificial rupture of CAT = Computerized axial tomography membranes Cath = Catheter ASA = Asprin CBC = Complete Blood Count ASAP = As soon as possible CBD = Common Bile Duct ASHD = Arteriosclerotic Heart CC = Chief Complaint Disease cc = Cubic centimeter au = Both ears CCU = Coronary Care Unit AV = Atrioventricular CDE = Common duct exploration ASO = Anti Streptomysin O ASMI = Anteroseptal myocardial infarction CF = Cystic fibrosis DP = Dorsalis Pedis Pulse CL = Chloride DPP = Dorsalis Pedal Pulse cl = Clear Dr. = Doctor CHF = Congestive Heart Failure DSD = Dry sterile dressing Medical Aspects Notes 173 Chol = Cholesterol dsg = dressing cm = Centimeters D.T. = Diptheria-Tetanus C.M.S. = Circulation, motion, DTR’s = Deep tendon reflexes sensation DT’s = Delirium tremens C.N.A. = Certfied Nurses Aide DVT = Deep vein thrombosis CNS = Central nervous system Dx = Diagnosis COPD = Chronic Obstructive Pulmonary Disease ECG = Electrocardiogram CPD = Cephalopelvic disproportion ECF = Extended care facility CPK = Creatine Phosphokinase EDC = Estimated date of confinement CPK-MB = Creatine Phosphokinase EDD = Estimated date of delivery Isoenzyme EDDU = Extracapsular cataract CPR = Cardiopulmonary Resuscitation extraction CS = Cesarean Section EENT = Eye, ear, nose & throat C & S = Culture and sensitivity EFM = Electronic fetal monitor C-Section = Cesarean section EGBUS = External Genitalia CSF = Cerebral Spinal Fluid Bartholin, Urethral, Skene CST = Contraction stress test EHL = Extensor Hallucese Longus creat = Creatinine EMS = Emergency medical services CRT = Capillary refill time EMT = Emergency medical techmician CVA = Cerebrovascular Accident EMT = Emergency medical technician, cva = costovertebral angle advance Cx = Cervix ENT = Ear, nose, throat CXR = Chest x – ray EOM = Extraocular muscles Epi = Epinephrine DAT = Diet as tolerated Epis = Episiotomy dc = Discontinue ESR = Erythrocyte Sedimentation D & C = Dilatation & Curettage Rate D5W = 5% dextrose in water ETOH = Alcohol decel = Deceleration E.T = Endotracheal dept. = Department EKG = Electrocardiogram DIC = Dissemination Intravascular EEG = Electroencephalogram Coagulation ER = Emergency room diff = Differential blood count Dig = Digoxin F = Female diast = Diastolic Fe = Female Dip = Diptherial FBS = Fasting blood sugar DFD = Digenerative joint disease FHM = Fetal heart monitor dk = Dark FHR = Fetal heart rate DKA = Diabetic Ketoacidosis FHT = Fetal heat tones DM = Diabetes Mellitus FM = Fetal movement DOA = Dead on arrival FOB = Foot of bed FS = Fracture simple/fracture compound FTP = Failure to progress IM = Intramuscular FUO = Fever of unknown origin IMI = Inferior myocardial F/U = Follow-up infarction Fx = Fracture I & O = Intake and output IOL = Intraocular lens G = Gravida IPPB = Intermittent positive GA = Gestational age pressure breathing GC = Gonococcal-Gonorrhea IUD = Intrauterine device GSC = Glasgow Coma Scale IUGR = Intrauterine growth Medical Aspects Notes 174 Gest = Gestation retardation GGPT = gamma glutamyl IUP = Intrauterine pregnancy transpeptidase IPUC = Intrauterine pressure Gm = gram catheter GNP = glomerulophritis I.V. = Intravenous Gi = Gastrointestinal IVCD = Intraventricular conduction GSW = Gun shot wound defect gtts = Drops IVP = Intravenous pyelogram gtt = drop IVPB = Intravenous Piggyback GU = Genitourinary GYN = Gynecology JT = Joint JVD = Jugular Venous Distention h, hr = Hour HA = Headache K = Potassium HCO3 = Bicarbonate radical Kg = Kilogram HCT = Hematocrit KJ = Knee jerk Hct = Hematocrit KUB = Kidney, ureter, & bladder HDL = High density lipids KVO = Keep vein open HEENT = Head, eye, ear, nose, & throat L, Lt = Left HEW = Health, Education & Welfare Lap = Laparotomy Hgb = Hemoglobin Lac = Laceration HIV = Human immunodeficiency virus Lat = Lateral HL = Heparin lock LBP = Lower Back Pain HNP = Hernieated Nucleus Pulposus LBT = Larynogotracheal Anesthesia HOB = Head of the bed Kit h.s. = Hour of sleep LDH = Lactate hydrogenase HTN = Hypertension LGA = Large for Gestational Age H.U.C. = Health unit coordinator LFD = Low forcep delivery H.W.B. = Hot water bottle LLE = Left lower extremity Hx = History LLL = Left lower lobe LLSB = Left lower sternal border IADH = Inappropriate antidiuretic LMA = Left mentum anterior hormone LML = Left middle lobe ICF = Intermediary care facility LMP = Last mestrual period ICU = Intensive care unit LMT = Left mentum transverse IDDM = Insulin dependent diabetes LNMP = Last normal menstrual period mellitus L.O.A. = Leave of absence LOA = Left occiput anterior LOC = Loss of consciousness LOP = Left occiput posterior LOT = Left occiput transverse NKA = No known allergies L.P.N. = Licensed practical nurse noc. = Night LS = Lumbosacral NPS = Nothing by mouth L/S = Lecithin sphingomyelin NSD = Normal spontaneous delivery LSA = Left sacrum anterior Nsg = Nursing LSB = Left sternal border NSR = Normal sinus rhythm LSP = Left sacrum posterior NST = Non stress test LST = Left sacrum transverse NSVD = Normal spontaneous vaginal LTB = Laryngeal tracheobronchitis delivery LTC = Left to credit (IV’s) N/V = Nausea and vomiting LTV = Long term variability NVD = Nausea, vomiting, diarrhea LUE = Left upper extremity LUQ = Left upper quadrant O2 = Oxygen Lytes = Electrolytes O2 Sat = Oxygen saturation Medical Aspects Notes 175 OA = Occiput anterior M = Male OB = Obstetrical MA = Mentum anterior OBS = Organic brain syndrome MAE = Moves all extremities OCT = Oxytocin challenge test- mCI = Millicures Oxytocin contraction test mcg = Mictogram OD = Overdose MCHC = Mean corpuscular hemoglobin OOB = Out of bed concentration om = Otitis media MCH = Mean corpuscular hemoglobin O & P = Ova and parasites concentration OP = Occiput posterior MCL = Midclavicular line OPS = Outpatient surgery MCV = Mean corpuscular volume OR = Operating room MDP = Technetium monodiphosphate ORIF = Open reduction and internal Mec = Meconium fixation meq. = Milliequivalent OS = Mouth MFD = Mid forcep delivery os = Left eye MgSo4 = Magnesium Sulfate od = Right eye M.I. = Myocardial infarction ou = Both eyes ml = Milliliter oz = Ounce ML = Midline mm = Millimeter P = Phosphorus MP = Mentum posterior p = Para MU = Milli Unit P&A = Percussion and auscultation MVA = Motor vehicle accident P.A. = Physician assistant n/a = not applicable PA = Pulmonary artery Na = Sodium PAC = Premature atrial contraction NB = Newborn PACU = Post anesthesia care unit NEG = Negative PAP = Pulmonary artery pressure NG = Nasogastric PAR = Post anesthesia recovery NIDDM = Non-insulin dependent Para = Paraplegic diabetes mellitus PAT = Paroxysmal atrial tachycardia Medical Aspects Notes 176 pc = After meals PRN = As the occasion arises PCIOL = Posterior chamber PROM = Premature rupture of intraocular lens membranes PCN = Penicillin P/S = Patient status PCO2 = Carbon dioxide PSVT = Proxysmal supra pressure or tension ventricular tachycardia PCWP = Pulmonary capillary PTA = Prior to arrival wedge pressure PT = Protime PCXR = Portable chest x-ray P.T. = Physical therapy P.E. = Pulmonary embolus Pt. = Patient Peds = Pediastric PTL = Preterm labor Per os = By mouth PTT = Partial thromboplastin PERRLA = Pupils: equal, round time to light and accommodation PVC = Premature ventricular PG = Phosphate dyglycerol contraction pg = Pregnant Pvt. = Private PGE = Prostaglandin ph = Acid base balance q = Every PID = Pelvic inflammatory q. am = Every morning disease q.d. = Every day PIH = Pregnancy induced QD = Every day hypertension PIPJ = Proximal q 2 h = Every two hours interphalangeal joint q.h.s. = Every bedtime Pit. = Pitocin q.i.d = Four times a day PKU = Phenylketonuria q.o.d. = Every other day PM = Pacemaker QRS = Segment of PMB = Post Menopapusal electrocardiograph bleeding QUAD = Quadriplegic PND = Proxysmal nocturnal QA, qs = Quantity sufficient dyspnea P.O. = Physician's order r, rt = Right p.o. = By mouth R = Rectal PO2 = Oxygen pressure RA = Rheumatoid arthritis (tension) RBBB = Right bundle branch PORP = Partial ossicular block replacement prosthesis RBC = Red blood count pos. = Positive RDS = Respiratory distress post. = Posterior syndrome Post-Op = Postoperative RE = Concerning / regarding pp = Post partum resp. = Respiratory PP = Postprandial Rh = Rhesus antigen PR = Pulse rate RIH = Right inguinal hernia PRIM = Primary RLE = Right lower extremity PRIMIP = Women bearing first RLL = Right lower lobe child RLQ = Right lower quadrant Medical Aspects Notes 177 RLSB = Right lower sternal SNF = Skilled nursing border facility Rm = room SOAP = Subjective, objective, RMA = Right mentum anterior assessment, plan RML = Right middle lobe SOB = Shortness of breath RMP = Right mentum posterior SP = Sacrum posterior RMT = Right mentum transverse S/P = Status post ROA = Right occiput anterior spec = Specimen ROM = Range of motion SpG = Specific gravity R.O.M. = Rupture of membranes SR = Sinus rhythm R.N. = Registered nurse SROM = Spontaneous rupture of ROS = Review of symptoms membranes r/o = Rule out STAT = Immediately ROP = Right occiput posterior STSG = Split thickness skin R.R. = Recovery room graft RSA = Right sacrum anterior STS = Stitches RSP = Right sacrum posterior STV = Short term variability RST = Right sacrum transverse subq = Subcutaneous RSB = Right sternal border SVD = Spontaneous vaginal RUQ = Right upper quadrant delivery R.T. = Respiratory therapy SVE = Sterile vaginal Rot. = Rotation examination ROT = Right occiput SVT = Supraventricular transverse tachycardia RTU = Ready to use syst. = Systolic RUE = Right upper extremity rupt. = Rupture T = Temperature Rx = Prescription T&A = Tonsilectomy and adenoidectiomy SA = Sacrum anterior T&C = Type and cross SAB = Spontaneous abortion tab = Tablet SCM = Sternocleidomastoid TAB = Therapeutic abortion SGA = Small gestational age Tachy = Tachycardia SGOT = Serum glutamic oxalix TAH = Total abdominal transaminase hysterectomy SGPT = Serum glutamic pyruvic TB = Tuberculosis transaminase TCB = To Call Back SI = Sacroiliac TELE = Telemetry SIDS = Sudden infant death Tet = Tetanus syndrome TIA = Transient Ischemia Sig. = Signify, significant Attack or label TIBC = Total Iron Binding SL = Lublingual Capacity SLR = Straight leg raising TIG = Therapeutic snds = sounds Interruption of Gestation Medical Aspects Notes 178 TID, tid = Three times a Day Vac-extract = Vacuum TKO = to keep down Extraction TOCO - Tocodynamometer Vag. = Vaginal TO = Telephone Order VD = Veneral Disease TPN = Total Parenteral V.D. = Vaginal Delivery Nutrition Vent. = Ventricular TPR = Temperature, Pulse, VENT = Ventilator Respiration Vfib = Ventricular TSH = Thyroid Stimulating Fibrillation Hormone VO = Voice/Verbal Order TURP = Transurethral VS = Vital Signs Resection of Prostate Vtach = Ventricular Tx = Treat Tachycardia Vtx = Vertex U, u = Units WBC = White Blood Count/Cells UA = Urinalysis WC = Wheelchair U.A. = Uterine Activity WNL = Within Normal Limits UC = Uterine Contraction Wt. = Weight Ung = Ointment UPI = Utereoplacental X = times Insuffieciency U.R. = Utilization Review URI = Upper Respiratory Infection US = Ultrasound USR-VDTL = Unheated Serum Reagin-Venereal Disease Research Lab UTI = Urinary tract Infection Medical Aspects Notes 179 SYMBOLS a before @ at/each b/4 before c with ca approximately, about c/o complains of m murmur p after s without ss one half increased, elevated or up decreased, diminished or down < less than > greater than -0- nothing change 's changes D decreased, diminished I increased, elevated 1+, + minimal or mild 2+, ++ slight 3+, +++ moderate 4+, ++++ severe, marked Medical Aspects Notes 180 Medical Aspects Notes 181 CASP 532 Dr. Jerry Fischer Psychiatric Rehabilitation Anthony, W., Cohen, M., & Farkas, M. (1990). Psychiatric rehabilitation. Boston: Center for Psychiatric Rehabilitation. 1. Research indicates that a diagnostic label itself provides rehabilitation counselors little information relevant to prescribing a rehabilitation intervention or predicting a rehabilitation outcome. 2. Psychiatric rehabilitation describes the disability that is the focus of rehabilitation. This does not mean that treatment must be done by psychiatrists or using psychiatric treatment methods. The term rehabilitation reflects the focus of the approach. 3. 1.7 to 2.4 million persons with severe psychiatric disabilities. Psychiatric Rehabilitation vs Psychiatric Treatment Psychiatric rehabilitation and the practice of psychiatric treatment (e.g., psychotherapy and pharmacotherapy) overlap to an extent. Ideally both occur in close sequence or simultaneously. Treatment techniques and rehabilitation techniques are often carried out in the same program, in same agency but different programs, and sometimes by the same person. However there are some traditionally perceived differences between rehabilitation and treatment: Medical Aspects Notes 182 Differences Rehab. Treat. Mission: Improved functioning and "Cure," symptom reduc- satisfaction in specific tion, or the development of environments therapeutic insights. Underlying No causal theory Based on a variety of causal theories that determine the nature of intervention Focus: Present and future Past, present, and future Diagnostic Assess present and needed Assess symptoms and possible content: skills and supports possible causes Primary Skills teaching, skills Psychotherapy, pharmacotherapy techniques: programing, resource coordination, resource modification Historical Human resource development psychodynamic theory; physical vocational rehabilitation; medicine physical rehabilitation; client-centered therapy; special education and learning approaches Medical Aspects Notes 183 Psycho-Social Aspects of Psychiatric Disabilities Following the deinstitutionalization of people with severe psychiatric disabilities in the '60s and '70 the National Institute of Mental Health (NIMH) created the Community Support Program (CSP). People served by CSP had the following characteristics: Median income: $3,900; 50% receive SS benefits; 10% are competitively employed; of the unemployed 9% are actively searching for work; 12% are married; 71% rarely or never engage in recreational activities with others In another survey by the National Alliance for the Mentally Ill (NAMI) data reported: 92% have a high school diploma; 60% have either post-high school training or attended college. Basic Principles of Psychiatric Rehabilitation (PR) 1. The primary focus of PR is on improving the competencies of persons with psychiatric disabilities. 2. The benefits of PR for the clients are behavioral improvements in the environments of need. 3. PR is eclectic in the use of a variety of techniques. 4. A central focus of PR is on improving vocational outcomes for persons with psychiatric disabilities. 5. Hope is an essential ingredient of the rehabilitation process. 6. The deliberate increase in client dependency can lead to an eventual increase in the client's independent functioning. 7. Active involvement of clients in their rehabilitation process is desirable. 8. The two fundamental interventions of PR are the development of client skills and the develoment of environmental supports. 9. Long-term drug treatment is an often necessary but rarely sufficient component of a rehabilitation intervention. Cautela, J. (1977). Behavior analysis forms for clinical Medical Aspects Notes 184 intervention. Champaign, Il: Research Press Co. Medical Aspects Notes 185 Schizophrenia: Postive (active) symptoms: Florid delusions (thought broadcasting; thought insertion; thought withdrawal) Hallucinations (auditory, visual, olfactory, tactile, etc.) Bizarre verbal behavior Distorted perceptions Negative symptoms: Decreased ambition Initiative Energy; poverty of speech Emotional responsiveness Poor self-care Use of Neuroleptics (antipsychotics, major tranquilizers) to treat active symptoms. Theory of schizophrenia associated with increased dopamine activity Use of antidopaminergics: Side Effects: Neuroleptic Malagnant Syndrome (NMS) a.k.a Extrapyramidal symptoms (EPS): a catatonialike state (unresponsive) associated with fever, obtundation (unfeeling), muscle rigidity, and unstable vital signs. Occurs with in the first 2 weeks of treatment or fafter an increase in dosage but can happen any time during neuroleptic use. depot fluphenazine fluphenazine (permitil, prolixin) halperidol (haldol) acetophenazine (tindal) perphenazine (trilafon) trifluperazine (stelazine, suprazine) thiothixene (navane) loxipine (loxitane) Medical Aspects Notes 186 molindone (moban) Dystonia: continual or intermittent muscle contraction that develops suddenly; torticollis (contraction of the neck rotating- chin points to other side); opisthotonos (head drawn back and spine arched backward; retrocollis (head is drawn back); oculogyric (forced eye movement upward) Akathisia: subjective desire to be in constant motion or inner sense of restlessness without any specific motor pattern. Parkinsonism: bradykinesia, rachetlike rigidity, resting tremor. Tardive dykinesia: choreoathetiod movements (like cerebral palsy; distal jerking movements); pill rolling; buccal- masticatory syndrome-oral, lips, tongue, jaw); infrequently in the trunk region of the body. glactorrhea (flow of milk) gynecomastia (enlarged breast in the male) menstrual and sexual dysfunction Antimuscarine-cholinergic: thiordazine (mellaril, millazine) mesoridazine (serentl) clozapine (clozaril) blurred vision narrow angle glaucoma dry mouth constipation urinary retention delayed or retrograde ejaculation memory dysfunction delirium sinus tachycardia decreased sweating Hot as a hare, blind as a bat, red as a beet, mad as a hatter Medical Aspects Notes 187 Delusional Disorders non-bizarre delusions (false beliefs that cannot be permanently changed by evidence to the contrary) antipsychotics: halperidol (haldol) side effects: SEE SCHIZOPHRENIA antidepressants: side effects SEE DEPRESSION Bipolar Disorder (Manic-Depressive Illness; Cyclothymia) Manic phase heightened motor activity rapid speech sleeps 1 to 2 hours a night euphoric extreme irritability low tolerance frustration grandiosity may begin abusing alchohol and other drugs impaired social judgement Switch process: psychobiological phenomenon whereby a behavioral change takes place Depressive phase depressed mood anhedonia weight loss/ weight gain insomnia/hypersomnia loss of energy feelings of worthlessness extreme guilt diminished cognitive abilities suicidal ideation Pharmacological treatment: antipsychotics: chlorpromazine (thorazine) Medical Aspects Notes 188 halperidol (haldol) SEE SCHIZOPHENIA FOR SIDE EFFECTS Lithium; side effects; lithium toxicity (excessive levels of lithium in the bloodstream can produce serious side effects, care must be taken to establish therapeutic levels that are not toxic to the system) Lithium is linked to renal function, sodium balance, and hydration. Lithium intoxication can result from dehydration, sodium depletion, diuretics, nonsteriodal anti-infammatory agents, emesis, diarrhea, infections, excessive perspiration, and declining renal function. Mild toxicity: nausia, vomiting, diarrhea, anorexia; coarse irregular tremors, weakness, facial tics, ataxia, apathy, sedation, confusion, giddiness Moderate toxicity: fever, bradycardia; tremor, muscle rigidity, choreoathetosis, dysarthria, tinnitus, blurred vision, nystagmus, impaired consciousness, restlessness, seizures Life-threatening toxicity: hypotension, cardiac arrhythmias, oliguria; stupor, coma, severe seizures Carbamazepine (for lithium non-responders): side effects: Drowsiness, ataxia, diplopia, blurred vision, vertigo, nausea, and vomiting. Allergic effects: urticaria, eosinophilia, exfoliative dermatitis, pruretic, and erythematous rashes. Water retention. Bone marrow suppression. Valporic acid: side effects: nausea, vomiting, gastrointestinal irritation Clonazepam (klonipin): side effects (this is a benzodiazepine) SEE DEPRESSION Medical Aspects Notes 189 Depression: (dysthymia, melancholic type, seasonal pattern) greater severity and duration than sadness Symptoms sadness anxiety irritability anhedonia guilt hopelessness worthlessness obsessive thoughts decreased memory poor concentration suicidal ideation social withdrawal social-occupational dysfunction no energy insomnia/hypersomnia decreased libido appetite disturbances diurnal variation in mood constipation delusions hallucinations Rule out organic causes. Pharmacotherapy: antidepressants Tricylics: amitriptyline (elavil, endep) imipramine (tofranil) doxepin (sinequan, adapin) desipramine (norpramin, pertofrane) nortriptyline (surmontil) protripyline (vivactil) Tetracylics maprotiline (ludiomil) Side effects of heterocylics: like anti-cholinergic effects Medical Aspects Notes 190 blurred vision narrow angle glaucoma dry mouth constipation urinary retention delayed or retrograde ejaculation memory dysfunction delirium sinus tachycardia decreased sweating Hot as a hare, blind as a bat, red as a beet, mad as a hatter also postural hypotension (decreased pulse, resulting in fainting when rising up to fast) Serotonin Uptake Inhibitors: fluoxetine (prozac) sertraline (zoloft) side effects: very low: sedation, anti-cholinergic, hypotension, and cardiac problems MAOI (monoamine oxidase inhibitors): isocarboxazid (marplan) phenelzine (nardil) tranylcypromine (parnate) side effects: hypotension, dizziness, headache, drowsiness, overstimulation (hypomania) insomnia, anxiety, constipation, nausea, diarrhea, abdominal pain Electroconvulsive therapy (ECT) watch out for memory loss. Medical Aspects Notes 191 Anxiety Disorders: Characteristics: subjective feelings of anticipation, dread, or apprehension, or by a sense of impending disaster associated with varying degrees of autonomic arousal and reactivity. Pharmacological treatment (anxiolytic agents): bensodiazepines: chlordiazepoxide (librium) diazepam (valium) oxazepam (serax) lorazepam (ativan) prazepam (centax) halazepam (paxipam) alpraxolam (xanax) buseprone (buspar) propanol (not approved for treatment) barbiturates (have by an large been replaced by benzodiazepines because of the sedation effects and high addiction potential, also rebound effect) side effects of benzodiazepines: addiction/abuse (tolerance and withdrawal) drowsiness increased reaction time impaired concentration ataxia agitation aggression Medical Aspects Notes 192 Somatoform Disorders (dysmorphobia, somatization disorder, conversion disorder, somatoform pain, hypocondriasis) Characteristics: presence of physical symptoms without organic pathological conditions. Unlike malingering individuals are at first undisturbed by the symptoms (la belle indifference; the beautiful indifference literally) before primary and secondary gains. No pharmaocological treatment per se. Multiple Personality Disorder and Dissociative Disorder Not Otherwise Specified MPD Characteristics: 2 or more distinct personalities within the same individual, each dominant at a particular time. DDNOS Characteristics: disturbance or alteration in integrative functions of identity, memory, or consciousness. Generally cognitive/behavioral techniques are employed. Borderline Personality Disorder (paranoid, schizotypal, histrionic, antisocial, narcissistic, avoidant, dependent, obsessive compulsive, and passive aggressive) Characteristics: varying levels of self-integration--cohesive to fragmented--, typically swinging between periods of stability and instability, impulsiveness, and acting out. Support of others in buttressing the sense of identity. pharmacotherapy (usually not productive) when used is to controll identified symptoms: lithium (see bipolar) carbamazepine (see bipolar) antipsychotics (see schizophrenia) tryicylics and MAOI (see depression) alprazolam (see anxiety) Medical Aspects Notes 193 CEREBRAL PALSY Muscle Relaxants: Valium (diazepam): is a sedative from the benzodiazepines family of drugs. It has the properties of tolerance and withdrawal (increased anxiety, insomnia, agitiation, and headaches). It is a highly psychologically addictive drug, as well as physically addictive after longterm use. Side effects include: overdose (depression of central nervous system, death); drowsiness, cognitive impairments, lightheadedness, ataxia, nausea, and paradoxial effects (increase in agitation, aggressiveness, hostility). Dantrium (dantrolene sodium): no information found. L-Dopa (Levodopa): an anti-Parkinson's disease drug. Side effects: prolonged use can induce psychoses (irrational behavior) also they include paradoxical effects (symptoms get worse: muscle spasticity, motor coordination failure). SEIZURE DISORDERS Dilantin (phenytoin) an anticonvulsant drug which takes a long time to act (60 minutes); side effects are paradoxical and are difficult to distinguish from the seizure disorder itself. Include drewsiness, mood changes, confusional states, and psychotic reations; irritability, depression, agitation, and visual hallucinations. Tegretol (carbamazepine) similar to antidepressants. Side effects include drowsiness, ataxia, double vision, blurred vision, dizziness, nausea, vomiting. It can be toxic to the blood. Mesantoin (mephenytoin) an anticonvulsant similar to and having the same characteristics as phenytoin, usually given with other drugs because it is more toxic. Secondary (given when the primary drug does not offer full protection against seizures): Phenobarbital is a sedative (barbituate) depresses the central nervous system. Side effects include tolerance, Medical Aspects Notes 194 withdrawal and physical addiction. Also confusion, aggression, and increased excitability, and psychosis when withdrawan abruptly. Primidone (Myosline): no information found Clorzepate (Tranxene) is a sedative from the benzodiazepines family of drugs. It has the properties of tolerance and withdrawal (increased anxiety, insomnia, agitiation, and headaches). It is a highly psychologically addictive drug, as well as physically addictive after longterm use. Side effects include: overdose (depression of central nervous system, death); drowsiness, cognitive impairments, lightheadedness, ataxia, nausea, and paradoxial effects (increase in agitation, aggressiveness, hostility). Celontin (Methsuximide): no information found Medical Aspects Notes 195 LYMPHOCYTES B Lymphocytes T Lymphocytes migrate to regulators and lymph nodes and controllers spleen functions: exposed to anti- memory cells gens produce (direct attack) antibodies helper cells (enhance B Humoral immunity lymphocytes) suppressor cells (halt B lymphocytes activity) Medical Aspects Notes 196 MEDICAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY The following are questions relevant to collecting and utilizing medical information for eligibility determination, case management, and vocational placement. ELIGIBILITY DETERMINATION Eligibility for Vocational Rehabilitation Services is contingent on the individual meeting the following criteria: 1. The individual meets the definition of an individual with a disability, i.e., an individual who has a physical or mental impairment. 2. The individual's physical or mental impairment constitutes or results in a substantial impediment to employment. 3. The individual can benefit in terms of an employment outcome from vocational rehabilitation services. 4. The individual requires vocational rehabilitation services to prepare for, enter, engage in, or retain employment. Documentation of the Disability: 1. Does the person have a disabling condition or a mental condition which results in a disability? 2. What is it? 3. If there is more than one disabling condition, what are the other disabling conditions? 4. What are the functional limitations resulting from the disability(ies)? 5. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Does a substantial impediment exist? A substantial impediment is defined as a physical or mental impairment (in light of attendant medical, psychological, vocational, educational, and other related factors) which impedes or will impede by the time the IPE is completed, an individual's occupational performance by preventing or making very difficult his or her obtaining, retaining, or preparing, for employment Medical Aspects Notes 197 consistent with his or her capacities and abilities (if no substantial impediment exists, the person is not eligible). Consider how the disability and resulting limitations relate to the following questions for the individual. 1. Has the individual lost jobs because of the disability? 2. Do they have an unstable work history? If so, has the disability contributed to this? 3. Are they prevented from doing the type of work they did previously because of the restrictions of the disability? 4. Do the restrictions of the disability limit the kinds of jobs they can do? 5. Will the individual have difficulty obtaining employment because of employer attitudes? 6. Is there evidence of problems in school which relate to the disability? 7. Is there evidence of problems in daily activities which relate to the disability? 8. Will their disability interfere with or cause problems with their preparing for an occupation commensurate with their capacities? (for example, would the disability cause problems completing necessary training?) 9. If currently employed: a. Are they underemployed because of their disability (working substantially below their capabilities - not just seeking promotion) b. Is their job in jeopardy and, if so, is this related to their disability? (Are modifications or changes in their job causing them difficulty in performing necessary duties and is the difficulty related to their disability?) c. Is the job aggravating their disability? The most important question is "what are the barriers that make it difficult for this individual to prepare for, obtain or keep a job and are those related to the disability?" This question not only determines substantial impediment but focuses Medical Aspects Notes 198 all planning. If a substantial impediment exists, are there attendant/related factors (e.g., history of dependence, insufficient work personality, insufficient work competencies, insufficient educational level, lack of family support etc.) that need to be considered? How do the attendant/related factors impact upon vocational functioning? Documentation of Benefit in Terms of Employment Outcome: There is a presumption that vocational rehabilitation services will lead to employment (to rebut this presumption, clear and convincing evidence must demonstrate that individual is incapable of benefit of services, thus an extended assessment). Following are questions to consider: 1. Are their services available which will enable the individual to correct, compensate or circumvent the identified functional limitations and vocational impediment? 2. What are the residual functional capacities as the relate to work? 3. How does the medical, psychological, diagnostic, and other information support the presumption of employment? 4. How do assets such as stability of disability, good work history, work personality, transferable work skills, family support, dexterity, strength, dependability, etc., support the presumption of employment? 5. Are their possible disincentives, e.g., SSDI, Workers Compensation, etc.? 6. Are they willing to relocate if necessary? Medical Aspects Notes 199 CASP 532 Dr. Jerry Fischer Eligibility Determination Learning objectives: students will be able to 1. Review case file information and synthesize relevant client information. 2. Apply vocational rehabilitation services eligibility criteria to relevant client information to ascertain client eligibility. 3. List an individual's possible functional limitations with regards to case file information. 4. Write an eligibility justification. The Case of Jesse LaRue Initial Interview and Application: This is a 49-year-old female applicant who was self referred. The initial interview took place in the IDVR office at which time VR policies and procedures were outlined in full. She was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). She signed a statement that she was aware of her rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated she had a ten year history of hypertension which was getting progressively worse. She experiences intermittent chest pains and fatigue. She is not taking any antihypertensives or other medications at this time. Social and Family History: The applicant is married for the second time. Her husband is recently retired from working in a lumber mill. She has two children from her prior marriage. One daughter resides in (a town 20 miles away), and her son, age 15, lives with the applicant. She has resided in (this town) for a long time. The applicant states that when she feels capable, she enjoys a variety of activities including walking, swimming, reading, sewing, traveling, and music. Educational and Employment History: Following high school graduation, the applicant obtained training as an LPN and maintains her license as a practical nurse. She worked 10 years as a home health nurse. She was employed for five years as (a local nursing home). Most recently she worked a rotating shift in the convalescence center at (a local hospital). She reports that her high blood pressure conditions has prevented her from returning to work. Vocational Interest: The applicant is unsure of a specific vocational goal but would like something that is flexible in hours and allows her to utilize Medical Aspects Notes 200 her transferable skills. She suggests becoming a social worker or a counselor. Counselor's Impressions: The applicant was well dressed and on time for her appointment. She was very thorough in describing her disability and limitations, as well as, her education and employment history. After the hour and a half session, she appeared to move more slowly. She walked to the entrance door in slower manner than when she arrived. General Basic Medical (GBM): The applicant was seen by (local doctor) on (recent date). It appears that a full review of all systems was done at that time. It was noted that the applicant had high blood pressure (142/95) due to a narrowing of her arteries. She has the beginning of a nephrotic syndrome (kidney disease) due to her high blood pressure. She may require nutritional supplements for the protein being lost. It is contraindicated for the applicant to stand for more than 20 minutes in one hour. The applicant also exhibits fatigue after routine exertion. Documentation of Disability: 1. Does the person have a condition which results in a disability? Yes, she is diagnosed with hypertension and nephrosis. 2. What are the functional limitation resulting from her disabilities? The applicant cannot stand for more than 20 minutes in one hour. The applicant has decreased stamina and needs rest after routine exertion. 3. Do these limitations affect vocational functioning and activities? Yes, the applicant is unable to continue to work as a Licensed Practical Nurse because she can no longer stand for the time required in her employment, and she no longer has the stamina to fulfill the tasks required of her in a 8 hour day. Documentation of a Substantial Impediment: This individual is a Licensed Practical Nurse. She has held employment positions as a nurse for the past 21 years. She can no longer be employed as a LPN because she is a person with hypertension. Her hypertension has limited her ability to stand for longer than 20 minutes in one hour, and she has decreased stamina which prevents her from working continuously during an 8 hour shift. Jesse LaRue has a diagnosed disability, hypertension, which is an impediment to her employment as an LPN. Documentation of Benefit in Terms of Employment Outcome: It is presumed that Jesse LaRue would benefit from vocational rehabilitation services. Jesse has indicated she would like to use her transferable skills or engage retraining to obtain employment in a job that is less physically demanding and with flexible hours. Jesse is in need of services consisting of skills training and counseling. Medical Aspects Notes 201 The Case of Jake Laslo Initial Interview and Application: This is a 17 year-old male applicant who referred by his resource room teacher. The initial interview took place at (local high school) at which time VR policies and procedures were outlined in full. He was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). He signed a statement that he was aware of his rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated he had pulmonary semilunar valve failure requiring surgery every one and a half to two years and a severe learning disability Social and Family History: The applicant is single and resides with his family. He has two older brothers: one with a substance abuse problems and the other sustained several head injuries and has emotional problems. His father presently is not working and has cancer of the ileum which requires a temporary ileostomy. The applicant had his first heart attack in the eighth grade. He spent a great deal of time over the past several years in and out of hospitals. He sees his cardiac specialist every six months. His mother is employed as a cook. Educational and Employment History: The applicant is presently a senior at (local high school). He will graduate in (date). Past employment consists of five months working at (local car dealer) doing janitorial work and one summer in youth manpower position through JTPA at the Humane Society caring for animal by cleaning cages, feeding, walking, and grooming them. Vocational Interest: The applicant expresses a strong interest in autobody repair. Counselor's Impressions: The applicant was a tall, slender, young man who looked his age. He had shoulder length hair which was clean and well kept. He was talkative and pleasant throughout the interview. He had trouble remembering his cardiologists name. He also could not remember his own address. He stated that this was due to his learning disability. He stated that he had given his vocational future a lot of thought. General Basic Medical (GBM): None given. Medical Information: Medical information was obtained from the applicant's cardiologist (nearby specialist). The applicant's most recent surgery was angioplasty to correct pulmonic valvular stenosis. In addition to the most recent angioplasty, he has had one in (date) and (date). The specialist feels that the applicant should be restricted from heavy labor or resistance exertion and should not lift more than 25 lbs. Psychological Information: On the WAIS-R this individual obtained a verbal IQ of 81, performance IQ of 110, with a full-scale IQ of 92. He was markedly deficient in information and arithmetic subtests. His reading skills are at less than 3rd grade and Medical Aspects Notes 202 arithmetic at 4th grade. Standard scores on his achievement test were both 57, two standard deviations lower than the full scale IQ. The psychologist is of the opinion that this individual is not a candidate for training requiring extensive academic preparation. However, he does have above average spatial skills. Documentation of Disability: 1. Does the person have a condition which results in a disability? 2. What are the functional limitation resulting from her disabilities? 3. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Documentation of Benefit in Terms of Employment Outcome: Medical Aspects Notes 203 CASP 532 Dr. Jerry Fischer Eligibility Determination Learning objectives: students will be able to 1. Review case file information and synthesize relevant client information. 2. Apply vocational rehabilitation services eligibility criteria to relevant client information to ascertain client eligibility. 3. List an individual's possible functional limitations with regards to case file information. 4. Write an eligibility justification. The Case of Joel Lowell Initial Interview and Application: This is a 36-year-old married male applicant who was referred by the Industrial Commission. The initial interview took place in the IDVR office at which time VR policies and procedures were outlined in full. He was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). He signed a statement that he was aware of his rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated he had lost his right leg below the knee in a logging accident in 1991, and he is currently using a wheelchair for mobility. His physician is (local physician) at (local medical facility), and he last saw the Doctor in (last month). Social and Family History: The applicant is married and lives with his wife and two children in (small local town). He enjoys fishing, hunting, woodworking, and shoe repair. Educational and Employment History: Joel graduated from high school. He attended vo-tech for diesel mechanics in 1976. After that time he has worked for the logging industry for the past 15 years. Financial Situation: He is receiving SSDI in the amount of $699.00 per month and Workers Compensation benefits of $1,200.00 per month. Vocational Interest: Joel is interested in possibly doing shoe repair or woodworking in his home. Counselor's Impressions: Joel was accompanied by his wife to the interview. She did much of the talking. He was polite, but seemed apprehensive about discussing his disability as well as his employment options. He emphasized the need to work in his home and to have a flexible schedule. He can only sit for a short period of time, and then he must lie down to relieve some of the Medical Aspects Notes 204 pain he experiences. He indicated these limitations are a major concern in an employment situation. General Basic Medical (GBM): None given. Medical Information: Dr. (personal physician) indicates in a consultation report dated (dated to time of accident), several days after the accident, that Joel sustained a severe open fracture with soft tissue loss of the right tibia as well as an L1 burst fracture resulting in paralysis. Another report from Dr. (personal physician) indicates surgery to save the right lower extremity had failed and a below the knee (BK) amputation was done. Additional information was obtained from Dr. (medical specialist), a neurologist. Dr. (medical specialist) indicates a final diagnosis of status post L1 fracture with paraplegia, neurogenic bladder and bowel secondary to previous diagnosis on intermittent catheterization and voiding, status post Harrington rods instrumentation and fusion, status post BK amputation (right), and mild carpal tunnel syndrome. Dr. (medical specialist) indicates Joel has a good range of motion about the major joints of the upper extremities with some mild tenderness in the left scapular area. Joel also has good range of motion about the major joint of his left lower extremities. It is noted that Joel has no discernable muscle power in his lower extremities, and no spasticity is noted. Documentation of Disability: 1. Does the person have a condition which results in a disability? 2. What are the functional limitation resulting from her disabilities? 3. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Documentation of Benefit in Terms of Employment Outcome: Medical Aspects Notes 205 The Case of Jed Lead Initial Interview and Application: This is a 22-year-old male applicant who was referred by his special education teacher. The initial interview took place in the IDVR office at which time VR policies and procedures were outlined in full. He was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). He signed a statement that he was aware of his rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated he had a learning disability since his youth. He believes he is a slow learner, has a form of dyslexia, and has confusion in his thought processes. He also states he has a low back impairment. He has pain in his neck, shoulders, and hip, as well as headaches. He states this pain is exacerbated by his current manual-labor position as a groundskeeper at (local school). He had seen an orthopedist in (western state), but he cannot remember the doctor's name, the date he visited the specialist, or the diagnosis. He also indicated he was diagnosed with manic depression. He has bouts of low self-esteem, depression, and has thought about suicide. He did not remember the name of the person or when he was diagnosed. He is not seeing a therapist in this regard. Social and Family History: Jed lives with his family, parents, and siblings in (local town). He enjoys reading and writing short stories; although, he has difficulty doing this. Educational and Employment History: Jed has been working as a groundskeeper at (local school) since August of 1992. The work there seems to exacerbate his low back problem. Prior to the groundskeeper job, he worked as a tire mechanic and janitor for short periods of time. Financial Situation: He is currently making minimum wage for 40 hours a week at his groundskeeping job. Vocational Interest: Jed is undecided about his vocational goal at this time. Counselor's Impressions: Jed was on time for his appointment. He fully elaborated about his disability. However, he had difficulty answering any direct questions. Several times he requested the questions to be re-asked. He did appear depressed. General Basic Medical (GBM): Dr. (local physician) reviewed all of Jed's systems and indicated that he suspected arthritis to be the cause of Jed's pain. He recommended a rheumatologic exam. Medical Information: Dr. (medical specialist), a rheumatologist, indicated there is no underlying joint abnormality which would cause Jed's problems. The doctor recommended an exercise program to improve musculoskeletal fitness and to lessen his aches and pains. Dr. (medical specialist) indicated that thyroid testing may be appropriate, as hypothyroidism could be responsible for the pain. Dr. (medical specialist), an endocrinologist, indicated after a serum thryoxine test that there was no conclusive evidence that Jed had a problem Medical Aspects Notes 206 with an endocrine disorder. Psychological Information: Psychological testing reports form 1991 were reviewed. On the WAIS-R Jed obtained a verbal score of 97, a performance score of 90, and a full scale IQ of 93. It was noted that Jed was nervous about the test and needed much encouragement to perform to his maximum. Jed's strengths were visual perception, synthesis into the whole through planning, and the ability to see cause and effect relationships. Weaknesses were in the use of words, ability to concentrate, short-term memory, and the ability to solve numerical problems. On the Woodcock-Johnson, Jed's scores reflected a discrepancy between achievement and ability. Jed had reading and math scores below average. Documentation of Disability: 1. Does the person have a condition which results in a disability? 2. What are the functional limitation resulting from her disabilities? 3. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Documentation of Benefit in Terms of Employment Outcome: Medical Aspects Notes 207 The Case of Jezebel Lidell Initial Interview and Application: This is a 44-year-old female applicant. The initial interview took place in the IDVR office at which time VR policies and procedures were outlined in full. she was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). She signed a statement that she was aware of her rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated she had numerous disabling conditions, including rheumatoid arthritis, drug/alcohol addiction, severe depression, chronic pain, and states that she has had eight major surgeries for various reasons. Social and Family History: Jezebel was born in (eastern state). She was raised in Quebec, Canada and speaks fluent French. She states she has not seen her family in 25 years, but they do communicate with her. She has been separated from her husband for 10 years, although she has never been legally divorced. She stated she has been trying to find him. Several years ago she lived in (western city) and became very active in the Gay Rights Movement. Through this she became a theatrical producer. She enjoys sailing and theatre. Educational and Employment History: Jezebel quit school during the 11th grade. She had a difficult time giving dates and time frames surrounding her employment history. She was fired from (local school) last summer, she gave no reason when asked about this. She presently is working planting seeds in a seed house for a plant geneticist. She worked for two years as a laundry worker, two months as a maid, four months as a cocktail waitress, and she worked on yachts in Hawaii doing the cooking, as well as sailing. She was a ski instructor. Financial Situation: The applicant is making minimum wage part-time at the seed house. She states she receives SSI for her alcoholism. Vocational Interest: Jezebel states she would like a job working with her hands in the arts. Counselor's Impressions: The applicant was 10 minutes late for her interview. She missed one interview and called the next day having realized it and rescheduled another just before when it was to take place a few weeks ago. Throughout the interview she was tearful and stated she cannot simply cope with the pain she is in. She said she was on several drugs at present, including an anti-depressant which she states is not working. She stated she sees her future as quite grim and has no hope of getting out of her present situation. She was upset about having to move, having lived in her apartment for the past seven years. She stated she does not have the money to pay $280.00 in rent. She said she has her alcohol problems undercontrol and that after this interview, "I'm just going to have myself a beer." from her description she has been depressed for several years and is presently on Methadone. General Basic Medical (GBM): A thorough review of systems indicated severe Medical Aspects Notes 208 back pain secondary to a fall; acute psychosis possibly secondary to a narcotic addiction withdrawal; possible depressive illness and/or unipolar depression; chronic severe fibromyalgia; suspected rheumatoid disease; severe bronchitis with and asmatic component. Medical Information: Dr. (medical specialist), a rheumatologist), sent a substantial packet of information on Jezebel. This information indicates she has severe rheumatiod arthritis, a variant form, which causes her significant pain. He states she has had emotional problems dealing with pain and that this has been very disabling. She is currently on pain medication in addition to Methotrexate. He indicates her current condition is not controlled well enough for her to be considered for any training. He also indicates that Jezebel has fibromyalgia. The report documents eight surgeries. Psychological Information: Results of the psychological evaluation indicate the following: Axis I diagnosis - polysubstance abuse, adjustment disorder with mixed disturbance of emotions and conduct, adjustment disorder with physical complaints, and Axis II diagnosis - histrionic personality disorder. Results of the MMPI-2 indicate self-centered hedonism, impulsiveness, high activity level, alienation, limited insight, limited cognitive control, or frustration tolerance. Furthermore, the MacAndrews Scale is indicative of a high propensity for substance use. Dr. (local psychologist) indicates that it is highly probable that she makes poor judgments as a response to stress. The client should be involved in careful contracting of specific vocational plans within the client's perceived limits of physical tolerance. Furthermore, it is important to get a clear understanding of the client's perception of what she wants, what is expected in training, and what she will be willing to do to get to her own vocational goal to avoid future misunderstandings about her capabilities. Documentation of Disability: 1. Does the person have a condition which results in a disability? 2. What are the functional limitation resulting from her disabilities? 3. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Documentation of Benefit in Terms of Employment Outcome: Medical Aspects Notes 209 The Case of JayShaun Lightning Killer Initial Interview and Application: This is a 19-year-old male American Indian from the Coeur d'Alene tribe who was self referred. The initial interview took place in the IDVR office at which time VR policies and procedures were outlined in full. He was provided with a pamphlet outlining VR services and explaining the Client Assistance Program (CAP). He signed a statement that he was aware of his rights and responsibilities as an IDVR applicant. Alleged Disability: The applicant stated he was admitted to (a major city psychiatric unit) after he began hearing voices. The voices were telling him he was no good, he was dumb and he was depressed. It told him, "we can't do things." He was stabilized at that time, given medication, and discharged. He had a second admission to the same hospital just recently. He was diagnosed Schizophrenic. Social and Family History: The applicant is single and lives with his parents. He is still finishing high school. He has lived all his life in (small town near by). He has one brother. He has a girl friend but reports it is not a serious relationship. He reports that he has used alcohol sporadically, but only a few episodes of drinking until intoxication. He reports smoking marijuana once. He says he does not have a history of drug abuse. Educational and Employment History: JayShaun attends a local high school and reports doing pretty well until this last year when thing began getting difficult. He reported he did not favor any of his classes. Other than helping out around the house JayShaun reports that he has not held any type of occupation. Vocational Interest: The applicant is unsure of a specific vocational goal. Counselor's Impressions: The applicant dressed appropriately for a teenager and was on time for his appointment. He showed little emotion and was very reserved. He answered questions with little description. He was very respectful. General Basic Medical (GBM): The applicant was seen by a physician at the time of admission to (a major city psychiatric unit). He was a well developed 19 year old male who had obvious acne on his face. A check of his major systems indicated no abnormalities. Psychiatric Evaluation: JayShaun was admitted to (a major city psychiatric unit) with suicidal thoughts, hallucinations, dysphoria, isolation, and an inability to function in the community. He was admitted on request of his psychiatrist because of disintegrating behavior at home and school. He was taking Trilafon depending upon how he felt. According to his psychiatrist he had been more withdrawn lately and was sad and depressed. He reported having a lot of pressures at school. He showed marginal impulse control. Psychological testing indicated ongoing thought disorder. His hospitalization was brief. He was stabilized on medications. JayShaun was diagnosed with Schizophrenia Form Disorder. Medical Aspects Notes 210 He requires supportive psychotherapy and chemotherapy. Individual therapy is provided on a weekly basis in conjunction with the chemotherapy. The objective is to enable him to adequately function in the community and to prevent recurrence of thought disorder and self-destructive behavior. Documentation of Disability: 1. Does the person have a condition which results in a disability? 2. What are the functional limitation resulting from his disabilities? 3. Do these limitations affect vocational functioning and activities? Documentation of a Substantial Impediment: Documentation of Benefit in Terms of Employment Outcome: Medical Aspects Notes 211 Documentation of Disability: 1. Does the person have a condition which results in a disability? Yes, JayShaun has been diagnosed as having Schizophrenia Form Disorder by (a major city psychiatric unit psychiatrist) 2. What are the functional limitation resulting from his disabilities? At present his most outstanding limitation would be his inability to adapt to the pressures of a community setting such as school which results in exacerbation of his psychiatric disability. His ability to maintain his medication regimen. His interpersonal skills may be lacking depending on cultural setting. 3. Do these limitations affect vocational functioning and activities? Yes, JayShaun's poor medication regimen and exacerbation of his schizophrenia by the pressures of a community setting which bring about suicide ideation, loss of impulse control, and disintegration of functioning at home and the community indicate that he would require assistance in finding suitable employment. Documentation of a Substantial Impediment: JayShaun Lightning Killer is young man who has had two psychotic episodes of schizophrenia exhibiting hallucinations and suicide ideation requiring hospitalization. He has shown an unwillingness to follow his medication regimen. He has poor impulse control. He is person who is withdrawn and may lack interpersonal skills (although this will be checked against his cultural background). These limitations would have a significant affect upon JayShaun's seeking suitable employment. JayShaun has a diagnosed disability, Schizophrenia, which is an impediment to his future employment. Documentation of Benefit in Terms of Employment Outcome: It is presumed that JayShaun Lightning Killer would benefit from vocational rehabilitation services which would lead to suitable employment. At present JayShaun is in need of assessment, counseling, vocational exploration, and possibly work adjustment services. Medical Aspects Notes 212 Dr. Jerry Fischer AIDS Update: Dr. David Ho’s break through in AIDS research has demonstrated that people in the early stages of HIV infection if given antiviral and protease inhibitors as a sort of ―cocktail‖ of drugs that the virus can be eliminated. People in advanced stages of AIDS can be given the same medications. The results are encouraging, however, long-term recovery cannot be expected. What is occurring is that AIDS is starting to become a chronic disability rather than a terminal one. Crucial to Dr. Ho’s research is the understanding that there is no dormant stage of HIV infection that the bodies defense system and HIV are at odds with each other from the first infection. At the beginning the HIV produces billions of copies of itself and the body counter acts by creating billions of immune cells. Eventually the immune system wears out and crashes. HIV Process and Drugs to Inhibit It 1. Aids virus consists of two strands of RNA and some enzymes encased in a coating. 2. When the virus encounters a T cell, proteins on the virus coating bind to both CD4 and co-receptors on the cell. 3. The virus then enters the cell. Its RNA is converted into double-stranded DNA by an enzyme called reverse transcriptase (RT). (RT inhibitor drugs such as AZT and 3TC, can disrupt the early stage of viral reproduction). 4. Next, an enzyme called integrase incorporates the virus’ genetic material into the T cell’s DNA. (Drugs called integrase inhibitors, which are designed to halt this process, are in development). 5. The viral DNA uses the cell’s manufacturing processes, directing it to churn out viral RNA and proteins. 6. Protease enzymes cut the viral proteins into shorter pieces so that they can be incorporated into new viruses. (Protease inhibitors block this stage of reproduction.) 7. The viruses bud off and attack other T cells.