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MEDICAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY

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					                                      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.

				
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