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L. Ebony Boulware

• Professor of Medicine
• Eleanor Easley Chair in the School of Medicine
• Chief, Division of General Internal Medicine in the Department of Medicine
• Director, Duke Clinical and Translational Science Award
• Vice Dean for Translational Sciences
• Professor in the Department of Family Medicine and Community Health
• Professor Track - V in Population Health Sciences
• Affiliate of the Center for Biobehavioral Health Disparities Research

https://medicine.duke.edu/faculty/l-ebony-boulware

Families could respond with their perspective on the problem and their suggestions for solutions pain medication for dogs with bite wounds generic motrin 600 mg on-line. Open pain treatment medicine purchase motrin 400mg with visa, ongoing communication with families of students with Asperger Syndrome creates a powerful alliance nerve pain treatment back buy motrin 600 mg cheap. Be aware that some families may have had negative experiences with other schools or teachers in the past sciatica pain treatment natural order motrin on line. Appendix C neck pain treatment guidelines discount motrin on line, on page 45 sports spine pain treatment center hartsdale ny purchase 600mg motrin overnight delivery, contains a worksheet with suggested questions to ask during your initial meetings with the parents. The education of and ways you can place children with teachers and staff is paramount. However, with appropriate assistance, children with Asperger Syndrome can engage with peers and establish mutually enjoyable and lasting relationships. It is critical that teachers of children with Asperger Syndrome believe this to be true and expect students with Asperger Syndrome to make and maintain meaningful relationships with the adults and other children in the classroom. In this way, the student with Asperger Syndrome would have a friend to listen to them and to report any potential conflicts with other students. The characteristics of Asperger Syndrome can cause peers to perceive a child with the disorder as odd or different, which can lead to situations that involve teasing or bullying. Many of the social interactions occur outside the classroom in the cafeteria and on the playground. To provide such a supportive you may consider a rotating assignment classroom, everyone involved should be of playground peer buddies for the educated about Asperger Syndrome, even the student with Asperger Syndrome. The academic and social success of young people with Asperger Syndrome can be greatly enhanced when the classroom environment supports their unique challenges. Step 5: Collaborate on the Educational Program Development the next key step in your preparations will be to participate in the development and implementation of an educational program for your student with Asperger Syndrome. Because the challenges associated with Asperger Syndrome affect many key aspects of development, the impact of the disorder on education and learning is profound. The school psychologist, social worker, classroom teacher, and/or speech pathologist are examples of educational professionals who conduct educational assessments. The classroom teacher also gives input about the academic progress and classroom behavior of the student. Annual goals must explain measurable behaviors so that it is clear what progress should have been made by the end of the year. Annual goals and short-term objectives can be about developing social and communication skills, or reducing problem behavior. Step 6: Manage Behavioral Challenges Many students with Asperger Syndrome view school as a stressful environment. Students with Asperger Syndrome rarely indicate in any overt way that they are under stress or are experiencing difficulty coping. All of these strategies can be effective in stopping the cycle of tantrums, rage, and meltdowns and can help the child regain control with minimal adult support. Rage If behavior is not diffused during the rumbling stage, the young person may move to the rage stage. At this point, the child is disinhibited and acts impulsively, emotionally, and sometimes explosively. Meltdowns are not purposeful, and once the rage stage begins, it most often must run its course. Adults should have developed plans for (a) obtaining assistance from educators, such as a crisis teacher or principal; (b) removing the student from the area [removing the upset student from the peer group is far less memorable for the peers than is moving the entire peer group away from the upset student]; or (c) providing therapeutic restraint, if necessary. This is often best accomplished by directing the youth to a highly motivating task that can be easily accomplished, such as an activity related to a special interest. Your classroom is already a diverse place, including many students with varying backgrounds, talents, difficulties, and interests. Just as every child with Asperger Syndrome is different, so is every school environment. These support strategies must be available to the child at all times and in all environments. Presented below are examples of sensory support strategies and fidgets that can be used to address common sensory problem areas for young people with Asperger Syndrome. For a more comprehensive guide to the interpretations of and interventions for sensory-related behaviors, see Asperger Syndrome and Sensory Issues: Practical Solutions for Making Sense of the World. Under-reactive to sensory stimulation Craves intense sensory experiences, such as spinning, falling, or crashing into objects. Unusually high/low activity level Constantly on the move or slow to get going and fatigues easily. A child with Asperger Syndrome may encounter at least one or more of the following: Examples of Sensory Needs and Supports Sample Sensory Problem Area Sample Support Strategy and Fidget Caesar has difficulty pouring a glass of water without Increase the weight of the container and spilling it. He may have trouble with motor decrease the amount of liquid in it, or fill cups or planning related to successfully completing a task. Greta cannot keep her hands and feet to herself Provide a visual or physical boundary for sitting, during circle time in her preschool classroom. He may like his outfit because of the lotion on the child, removing irritating clothing soft cotton texture and dislike jeans because of the tags, or using a fragrance-free detergent. A standard set of interventions should not be prescribed for individuals with Asperger Syndrome, as each student will have individual needs. Priming may occur the day before an activity, the morning of it, the class period before, or even at the beginning of the class period when the activity will be completed. Students with Asperger Syndrome also have a difficult time neurologically shifting from one thought process to another. For this reason, grouping like questions together on quizzes and tests will be very helpful. Common examples of these accommodations include: Allowing additional time for the student to complete tasks Shortening tasks or reducing the number of tasks for student to complete Outlining precisely what information the student should learn from reading Giving students a model to follow of what is expected on assignments Modifying assignments can be accomplished easily without drawing undue attention to the student. Students with Asperger Syndrome may also read slowly and have trouble discerning important facts from irrelevant information. Highlighted text and study guides help these students maximize their reading time. For example, if an essay will be graded on neatness and spelling, as well as content, this must be explained to the student. Therefore, care should be taken when designing visual supports for young people with Asperger Syndrome to ensure that they are either used by everyone in the class or that they are not obvious to others in the class except the teacher and student with Asperger Syndrome. Although the use of visual supports may benefit all students, they are essential for students with Asperger Syndrome. As each activity is completed, upcoming activities it can be erased, crossed out, or checked off. List of test reminders: A study guide that lists content and Prepared in advance Ensures that the student knows textbook pages covered in the test by the teacher and when a test will occur and what is helpful. The teacher the day before the assumes responsibility for test developing it initially, but then works with the student to complete the task independently. Including or whiteboard prepared for changes in routine the responsibilities of the student in Prepared at least 1 the activity helps her complete the day in advance by the Reduces stress and anxiety that activity with minimal stress/anxiety. List of homework assignments: Students with Asperger Syndrome Prepared in advance Assists the student in need written details of homework. Cue to use home base: Students with Asperger Syndrome A small card, Prompts the student to leave often do not know that they are approximately the size class to lower her stress/anxiety entering the cycle for meltdown. A home base is a place where the student can go: To plan or review daily events To escape the stress of their current environment To regain control if a tantrum, rage, or meltdown has occurred the location of home base is not important; it can be a bedroom or resource room. What is important is that the student with Asperger Syndrome perceives the home base as a positive and reassuring environment. For example, when a student goes to home base at school, she takes her assignment with her. For instance, completing a math assignment is not a choice, but the color of pencil to use when doing the assignment could be determined by the student. Teachers must take this into consideration and make appropriate accommodations for students with Asperger Syndrome. While handwriting is typically emphasized throughout the early school years, people encounter fewer requirements to use handwriting, other than providing a legal signature, as they get older. Fluent typing skills will be useful to students with Asperger Syndrome as they enter high school, college, and the working world. Students with Asperger Syndrome tend to enjoy learning more about their special interests and are motivated by them. Incorporating these special interests into the curriculum of the student with Asperger Syndrome is one way of making tasks seem interesting, when they may initially be overwhelming or meaningless to the student with Asperger Syndrome. Homework may present major concerns to students with Asperger Syndrome, such as those described below: Homework generally requires handwriting, which can be cognitively and physically challenging for students with Asperger Syndrome. The homework checklist on the following page can be used to aid in this decision making process. Spoken language Written language Sign language Communication device Combination of the above (please describe): 5. Despite their desire to have friends and interact with others, children and youth with Asperger Syndrome have difficulties with social skills. Thus, it is important that social skills be included as a part of the curriculum for students with Asperger Syndrome. Effective instructional strategies include: Direct instruction Social narratives Cartooning Power card strategy Incredible 5-point scale these strategies are described in more detail on the following pages. Effective use of a social skills curriculum should include an instructional sequence that facilitates learning and generalization of social skills. Parents can assist with generalization of social skills by observing home and community-based events in which the child is expected to use the skill. A conversation starter card, the size of a business card or trading card, contains five or six different subjects that same-age peers might like to discuss. Topics must be gender-sensitive, as boys and girls find different topics interesting. Young people with Asperger Syndrome can practice the scripts with other peers or an adult, and then use them in real-life situations. Scripts are used for children with Asperger Syndrome who have difficulty generating novel language when under stress, but have excellent rote memories. The Power Card can be carried with the child, placed on the corner of the desk, or stuck inside a book, notebook, or locker. A sample Power Card scenario and Power Card was created for David, a 9-year-old boy with Asperger Syndrome, who whose current interest is high-end exotic cars, including the Aston-Martin driven by screen legend James Bond. James Bond knows: It is sometimes hard to wait, but your turn will eventually come. The Incredible 5-Point Scale provides a clear, concrete visual aid that uses numbers to represent abstract ideas, such as feelings, emotions, and behaviors. The Incredible 5-Point Scale helps people with Asperger Syndrome learn to: Better understand their emotions and reactions to events in their lives Modulate their responses and behaviors in difficult situations To use the Incredible 5-Point Scale, students and adults identify a behavior or problem situation and determine a rating scale for the behavior choices available to the young person with Asperger Syndrome. Using the scale and accompanying social narrative, young people with Asperger Syndrome are taught to recognize the stages of their specific behavioral challenges and learn methods to self-calm at each level. Sample Use of the Incredible 5-Point Scale Larry, an 11-year-old boy with Asperger Syndrome, is very soft spoken. The transition considerations checklist for pre-K through school to work and the transition timeline from middle school through senior year (or 1822) are helpful for this process.

Neuralgic pain arising in the the absence of signs of infection treatment for shingles pain mayo clinic 400mg motrin, one should absence of evidence of neurological disease think of migraine pain neck treatment 400 mg motrin with visa, migrainous neuralgia and occurs in postherpetic neuralgia abdominal pain treatment guidelines motrin 600mg with visa, when there temporal arteritis kearney pain treatment center discount 600 mg motrin. The trigeminal sensory derma male pain medication for dogs side effects order 600 mg motrin visa, aged between 25 and 40 treatment for post shingles nerve pain purchase motrin line, and the attacks tome always encloses the painful parts, and of pain, which last for a short period varying the ophthalmic area is least often affected. Attacks can occur once or minutes, but it can progress to a period of pain more in 24 hours, and typically waken the lasting several hours. A group of very similar if the patient is seen during an acute attack, attacks can occur over several weeks or spasm of the muscles of the ipsilateral side of months, and disappear, only to return in a the face will be noted. The pain carbamazepine (Tegretol) starting with a dose is frequently precipitated by alcohol ingestion. It radio-frequency rhizotomy may be required is part of a giant-cell arteritis affecting many in patients uncontrolled by medical therapy. These patients have to diagnose because although it is uncommon, often consulted many specialists and have had its complications are serious, and it is innumerable unsuccessful trials of medical or amenable to treatment with systemic steroids. They are often depressed, Neuralgic pain is sharp and burning in but this can be as much a function of their character, and is interspersed with periods unremitting ailment as of psychological which are either free from pain or with a imbalance. It occurs in disease affect combination of psychotropic drugs and ing the nerves, when there will be evidence of psychotherapy giving the greatest chance of altered sensation either to light touch or to a success. It is a fibromuscular structure consisting of the following layers from without inwards: 1. Nasopharynx Nasopharyngeal Tonsil the part of pharynx which lies above the soft palate and behind the nasal cavity is called It is a collection of lymphoid tissue under the the nasopharynx. The collection disappears as the the posterior wall is formed by the anterior child starts growing. This pharyngeal openings of the eustachian tubes lymphoid collection has no capsule. Ascending palatine branch of facial Anteriorly the oropharynx opens in the artery. Paratonsillar vein Tonsils emerges on the lateral surface and pierces the superior constrictor muscle to end in the Tonsils are organised lymphoid structures common facial vein and pharyngeal plexus of situated between the faucial pillars. A fold of mucous emerge from the lateral aspect and end in the membrane, plica semilunaris connects the jugulodigastric group of deep cervical nodes. The medial surface of the inner ring consists mainly of the naso tonsil shows a number of crypts. An intraton pharyngeal tonsil, peri-tubal lymphoid sillar cleft is seen at the upper part of the tonsil tissues, faucial tonsil and lingual tonsil. The and is a remnant of the second pharyngeal efferents from this ring drain to lymph nodes pouch. The lymphoid tissues have a protective by a fibrous capsule attached loosely to the function. Laryngopharynx (Hypopharynx) Tonsillar bed It is formed by loose areolar this part of the pharynx lies behind the larynx tissue, pharyngobasilar fascia, superior and partly surrounds the larynx. Superiorly, constrictor muscle and buccopharyngeal it communicates with the oropharynx and fascia. The postcricoid region is the lower part of the Pyriform Fossa laryngopharynx and is formed by mucosa extending from the upper to lower border of the pyriform fossa is a recess on each side of the cricoid cartilage. It is bounded medially by the aryepiglottic fold, laterally by the thyrohyoid Posterior Pharyngeal Wall membrane in the upper part and medial surface of the thyroid cartilage in the lower this part of the hypopharynx extends from part. Superiorly the fossa is separated from the level of the hyoid bone down up to the the vallecula by the pharyngoepiglottic fold. The rest of the the fossa communicates below with the mucosa is included into the lateral pharyngeal upper end of the oesophagus. The circular layer is formed by the palati are supplied by the cranial root of the superior, middle and inferior constrictors accessory through the vagus. Tensor palati is which form the side and posterior wall of the supplied by the mandibular division of the pharynx. The pharyngeal closure of the nasopharyngeal isthmus and, muscles help in deglutition. This is a rounded ridge which appears on the posterior pharyngeal wall during closure of Nerve Supply the nasopharyngeal isthmus. The posterior free border of the soft palate comes in contact Pharynx is supplied through pharyngeal with this ridge to close the nasopharynx plexus which lies mainly on the middle during deglutition. This is formed by the contraction of upper fibres of the superior pharyngeal branches of the vagus and glosso constrictor and the palato-pharyngeus muscle. The recurrent laryngeal and oropharyngeal isthmus have a nerve sends a branch to the inferior protective role. The pharynx plays an important role in It is a fibromuscular structure attached to the speech. Other muscles which take part in its formation Functions of the Pharyngeal are levator palati, palatoglossus, palato Lymphoid Tissues pharyngeus and musculus uvulae. Laterally the soft palate is attached to the the exact functions of the subepithelial pharynx. Once the cricopharynx opens, the location of the faucial tonsils and nasopharyn food passes into the oesophagus. It is carried geal lymphoid tissues suggests that these down by peristaltic waves. The cardiac structures are concerned with sampling of air sphincter opens in response to the peristaltic and food and thus constantly monitor the waves and food thus enters the stomach. Antibodies are formed against In addition, deglutition also serves the these microorganisms and thus help in the following functions. Disposal of dust and bacteria-laden lymphoid structures atrophy with the growth mucus conveyed by ciliary action to the it appears that this defence mechanism is pharynx from nasal passages, sinuses, mainly active during childhood. Opening of the pharyngeal ostia of Deglutition is a process by which food passes pharyngotympanic tubes, to establish from the oral cavity into the stomach through equalisation of pressure on the outer and the oesophagus. The resting intrapharyngeal pressure is First stage (voluntary) After the food is masti equal to the atmospheric pressure. During cated and made into a bolus, the posterior part swallowing there is a transitory rise of about of the tongue propels the food into the 40 mm Hg pressure at the pharyngo-oeso oropharynx. During Second stage (pharyngeal stage) In this stage swallowing this pressure falls abruptly just food passes from the oropharynx into the before the pharyngeal peristaltic wave reaches oesophagus. This indicates a relaxation of the raised and laryngeal inlet gets closed to sphincter. Breathing abrupt closure coincides with the arrival of the momentarily stops and the nasopharyngeal pharyngeal peristaltic wave and has the isthmus remains closed. The pharynx is function of preventing reflux while peristalsis elevated and the pharyngo-oesophageal is occurring in the upper oesophagus. When junction opens to receive the bolus which is the bolus has passed further down the oeso pushed down by contraction of the circular phagus, the pressure in the pharyngo muscles of the pharynx. This is due to dehydration causing decrea Two sounds can be heard on auscultation over sed salivary secretion and drying of the the oesophagus during swallowing. Impulses from those receptors the commencement of the act and is prob are conducted along fibres in the ninth and ably due to the fluids impinging on the tenth nerves. The second sound resembles a bubbling or secretion or by local anaesthesia of the trickling noise and occurs at a variable interval of 4-10 seconds after the first sound pharyngeal mucous membrane. It seems to be replaced by a few discrete squirting related to intracellular osmolarity. When Intravenous hypertonic saline or a high a solid bolus is swallowed, the second intake of salt with low water intake, sound may be absent. This osmotic the sensation of thirst is composed of two effect acts on the osmoreceptor neurons in components. Pain from the oropharyngeal diseases may be referred to the ear (referred otalgia). This can result from a variety of lesions in the oral Difficulty in Respiration cavity, pharynx and oesophagus (Fig. Trauma, tumours and infections can lead to the lesions could be inflammatory, paralytic airway obstruction. Regurgitation occurs in paralytic lesions of the soft palate when the ingested Palatal paralysis or sometimes adenoidectomy material regurgitates into the nose. Paralysis lead to improper closure of the nasopha of the pharynx may lead to dysphagia as well ryngeal isthmus with resulting hypernasality as to aspiration into the trachea. This the anterior two-thirds of the tongue for defect is called rhinolalia clausa. It should not be put on posterior-third of the tongue to avoid Ulceration of Pharyngeal Mucosa gagging. Surface of the hard and soft palate is Ulceration of the pharynx may be manifes noted for any clefts, ulcers or tumour. The postnasal discharge which indicates a Cervical Lymphadenopathy nasal disease is seen trickling behind the soft palate. This may be the cause for many Enlargement of the cervical nodes is com pharyngeal symptoms. The posterior pharyn monly due to infective or neoplastic lesions geal wall is seen bulging in case of retro of the oral cavity, pharynx, larynx and pharyngeal abscess. The patient is asked to open the mouth and an inspection Palpation of the oral vestibule is done. The Finger palpation is necessary to examine the patient is asked to lift the tip of the tongue inside of the oral cavity and pharynx and and orifices of the submandibular ducts and should be routinely done. Movements of the mouth) and that of the floor of the mouth is tongue are noted for paralysis or neoplastic necessary for evaluating the extent of a infiltration. Palpation of the tonsils Faucial pillars and condition of the tonsils and base of the tongue is necessary to diagnose are noted. Pressure by the tongue depressor certain infiltrative growths which may not squeezes the debris from the tonsillar crypts show on the surface. The colour of the mucosa, process may be felt on palpating through the ulcerations and membrane formation are tonsillar fossa. Palpation of the neck for lymph looked for in the oropharyngeal and buccal nodes forms an essential part of the mucosa. Common Symptoms of Oropharyngeal Diseases 251 Investigations Radiological Investigation Haematological Tests A plain X-ray of the neck (lateral view) provi des clues for evaluating pharyngeal diseases. Like haemoglobin estimation total and X-ray of the chest, lateral view of the naso differential counts are particularly required in pharynx, X-ray of the mandible are the other ulcerations of the oral cavity and oropharyn views which may prove useful. Some of the common diseases of titis can be caused by staphylococcal, otolaryngologist interest are described here. Stomatitis is a general term for diffuse inflam the infection is common in debilitated mation of the mouth. Inflammation of the oral patients, marasmic children and patients mucosa can be caused by local and systemic receiving broad-spectrum antibiotics. These Local Causes patches may coalesce to form a membrane Traumatic stomatitis the trauma may be due which can be removed. Diagnosis can be to ill-fitting dentures, hot foods, corrosives, confirmed by microscopical examination that simple cut of the mouth, too vigorous use of a show the fungal hyphae. The underlying debility Infective stomatitis Inflammation of the oral needs attention. Viral infections like herpes simplex or of this disease of unknown aetiology appear herpes zoster start as small painful vesicles as dull white or milky dots in a lace-like which later ulcerate, involving the lip, arrangement. Systemic Causes Pemphigus Deficiency of vitamins like the B-complex Bullous lesions without erythema around group and vitamin C also cause mucosal them occur on the oral mucosa and the skin. Idiopathic Oral Fibrosis Mucosal ulceration of the oral cavity and (Submucous Fibrosis) pharynx may be the presenting feature of this consists of progressive fibrosis involving agranulocytosis, leukaemias, polycythemia and infectious mononucleosis. Recurrent Ulcerative Stomatitis Aetiology (Aphthous Ulcers) the exact aetiology is not known but various Recurrent painful ulcerations of the oral predisposing factors are betel-nut, pan and mucosa is a common condition of unknown tobacco chewing. Various factors like viruses, endo than males and the disease is most common crine disturbances, psychosomatic factors, in the age group of 30-50 years. The lesions, single or Various stages of the disease are the following: multiple, present as small superficial ulcers 1. These usually occur complains of soreness and intolerance to in the gingivobuccal groove, tongue or buccal spices and salts. There is be given to orodental hygiene and underlying pallor over the soft palate and fauces. The incisor bite is reduced from this is a disease of unknown origin, charac the normal 4. The mucosa terised by ulcerations of the oral cavity, of the oral cavity and oropharynx looks 254 Textbook of Ear, Nose and Throat Diseases pale and rigid. The vestibule of mouth is fibrous tissue and infiltration by lymphocytes obliterated and the patient cannot puff out and plasma cells. The anterior faucial pillars are Treatment markedly fibrosed with marked limitation of movement of the soft palate.

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Syndromes

• Changes in alertness
• Dilated pupils
• Older or very young age
• Amount swallowed
• Runny nose
• A mental disorder called psychogenic polydipsia
• Demyelination (damage and loss of the fatty insulation surrounding the nerve cell)

References

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