Brandi Page, M.D.

• Associate Residency Program Director, Radiation Oncology Residency, Johns Hopkins University School of Medicine
• Assistant Professor of Radiation Oncology and Molecular Radiation Sciences

https://www.hopkinsmedicine.org/profiles/results/directory/profile/10000789/brandi-page

Her parents say that she started walking at the age of 14 months and since then has always seemed clumsier and had more injuries than other children depression definition webmd order wellbutrin 300 mg online. She has had increasingly frequent pain with exertion since starting a soccer program 3 months ago goldberg depression test accuracy buy wellbutrin 300mg cheap. She has been taken to the emergency department three times during the past 3 weeks because of concern about possible fractures; x-rays showed no abnormalities anxiety kidney pain discount wellbutrin 300 mg mastercard. Examination shows numerous paper-like scars over the torso and upper and lower extremities depression definition for business generic wellbutrin 300mg otc. The hips and the joints of the upper and lower extremities are hypermobile depression in dogs discount wellbutrin 300 mg with visa, including 25 degrees of genu recurvatum bipolar depression famous people order wellbutrin 300mg on line, thumbs that may be extended to touch the forearms, and flexibility at the waist, with palms easily touching the floor with straight knees. C C E D B A B E C B 119 Psychiatry Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient Behavioral Health Normal processes, including adaptive behavioral responses to stress and illness Psychotic disorders Anxiety disorders Mood disorders Somatic symptoms and related disorders Factitious disorders Eating disorders and impulse control disorders Disorders originating in infancy/childhood Personality disorders Psychosocial disorders/behaviors Substance abuse disorders Adverse effects of drugs Nervous System & Special Senses Other Systems, including Multisystem Processes & Disorders Social Sciences Communication and interpersonal skills Medical ethics and jurisprudence Physician Task Diagnosis, including Foundational Science Concepts Pharmacotherapy, Intervention & Management Site of Care Ambulatory Emergency Department Inpatient Patient Age Birth to 12 13 and older 5%­10% 65%­70% 10%­15% 5%­10% 1%­5% 65%­70% 30%­35% 60%­65% 20%­30% 5%­10% 10%­15% 85%­90% 120 1. A 3-year-old girl is brought to the physician by her parents because they are concerned about her behavior. She often refuses to comply with their requests and sometimes throws 3- to 5-minute temper tantrums. They report that she dawdles at bedtime and requires frequent direction and assistance in preparing for bed. Her preschool teacher notes that she is active and talkative without being disruptive and is beginning to demonstrate more interactive play with her peers. Her first word was at the age of 11 months, and she began walking without assistance at the age of 14 months. On mental status examination, she initially hides behind her mother but warms to the interviewer after a few minutes and begins playing with toys in the office. He has been drinking heavily since he was passed over for a job promotion 3 days ago. He has no personal history of psychiatric disorders and no personal or family history of alcohol abuse. A previously healthy 18-year-old woman is brought to the physician for evaluation because of loss of appetite, sleeplessness, and extreme irritability for 3 weeks. After missing many practices, she quit the college softball team that she previously enjoyed. She often feels tired and has difficulty sitting still and concentrating on schoolwork. A 57-year-old man comes to the physician accompanied by his wife because of a 2-year history of fatigue. He thinks that the fatigue is affecting his concentration and performance at work. His wife says that he snores frequently during the night and sometimes wakes up gasping for air. A 52-year-old woman whose husband died 2 months ago consults a physician because of headaches and feelings of uncertainty. She describes the headaches as a band around her head; they occur unpredictably and are not accompanied by any other symptoms. While talking with the physician, the patient begins to cry and talk about her deceased husband; she feels her life is empty now and worries about her future. A 47-year-old man is brought to the emergency department by police after he was found eating garbage from a dumpster behind a restaurant. He says that he just came to this town and that he is homeless, so he has no money for food. He admits to several psychiatric hospitalizations in the past but says that he no longer needs medication. On mental status examination, his speech is clear, but his thought process is disorganized with many loose associations. At several times during the interview, he appears to be preoccupied with internal stimuli. A 32-year-old woman is brought to the emergency department because of fever, hallucinations, agitation, and confusion for 8 hours. There is a holosystolic murmur; the abdomen is tender, and the liver edge is palpable 3 cm below the right costal margin. A 10-year-old boy is brought to the physician because of increasing behavior problems in school since starting 5th grade 3 months ago. His teacher states that he is unable to sit quietly through a classroom period and frequently disrupts the class and interrupts other children while they are talking. His parents report that he has always been an active child and are concerned because he is inattentive when he runs or walks. During examination, he fidgets with his hands and feet and is easily distracted from completing a task. A 27-year-old woman is brought to the emergency department 1 hour after a friend found her barely arousable in her disorderly apartment with a nearly starving cat. Physical examination shows small pupils, cracked lips, and bruises and scratches over the upper extremities. Mental status examination shows mild obtundation, blunted affect, and slow, incoherent speech. A healthy 9-year-old boy is brought to the physician by his parents because they are concerned that he dislikes attending school. He misses school at least 1 day weekly because his mother is exhausted from fighting with him to attend. At home, he tends to stay in the same room as his mother and will sometimes follow her around the house. When his parents plan an evening out, he often becomes tearful and asks many questions about when they will return. He makes brief eye contact and speaks in a low volume, becoming tearful when questioned about being away from his mother. A 47-year-old woman is brought to the physician by her husband because of bizarre behavior for 1 week. Her husband says that she makes no sense when she speaks and seems to be seeing things. She also has had difficulty sleeping for 2 months and has gained approximately 9 kg (20 lb) during the past 5 months. He also notes that the shape of her face has become increasingly round and out of proportion with the rest of her body despite her weight gain. Physical examination shows truncal obesity and ecchymoses over the upper and lower extremities. Mental status examination shows pressured speech and a disorganized thought process. One day after admission to the hospital for agitation and hallucinations, a 19-year-old man has the onset of severe muscle stiffness that prevents him from rising out of bed. Physical examination shows generalized severe rigidity of the upper extremities bilaterally. A 32-year-old woman comes to the physician because of a 3-week history of depressed mood. She says that she has always had a busy schedule, but lately she has not had her usual amount of energy and has had difficulty getting up and going to work. She describes herself as normally a "hyper" person with energy to perform multiple tasks. During the past 10 years, she has had similar episodes in which she has had depressed mood associated with a decreased energy level that makes her feel "slowed down. She sometimes goes through periods when she feels a surge in energy, sleeps very little, feels at the top of her mental powers, and is able to generate new ideas for the news station; these episodes never last more than 5 days. She says that she loves feeling this way and wishes the episodes would last longer. A 77-year-old woman is brought to the emergency department by her husband because of agitation and confusion for 3 hours. He states that she has been intermittently crying out and does not appear to recognize him. A routine health maintenance examination 3 days ago showed no abnormalities except for mild memory deficits. Physical examination shows no abnormalities except for mild tenderness to palpation of the lower abdomen. Mental status examination shows confusion; she is oriented to person but not to time or place. A 14-year-old boy is brought to the physician by his mother after she found an unsmoked marijuana cigarette in his bedroom. When interviewed alone, the patient reports that his friends heard about smoking marijuana and acquired some from their peers to find out what it was like. He requests that his teachers not be informed because they would be very disappointed if they found out. On mental status examination, he is pleasant and cooperative and appears remorseful. An otherwise healthy 27-year-old man is referred to a cardiologist because of three episodes of severe palpitations, dull chest discomfort, and a choking sensation. The episodes occur suddenly and are associated with nausea, faintness, trembling, sweating, and tingling in the extremities; he feels as if he is dying. Within a few hours of each episode, physical examination and laboratory tests show no abnormalities. A 42-year-old woman is brought to the physician by her husband because of persistent sadness, apathy, and tearfulness for the past 2 months. She has a 10-year history of systemic lupus erythematosus poorly controlled with corticosteroid therapy. Physical examination shows 1-cm erythematous lesions over the upper extremities and neck and a malar butterfly rash. A 27-year-old man is brought to the emergency department by police 2 hours after threatening his next door neighbor. Three months ago, he noticed that his neighbor installed a new satellite dish and says that since that time, she has been watching every move he makes. He has not had changes in sleep pattern and performs well in his job as a car salesman. A 9-year-old girl is brought to the physician by her adoptive parents because they are concerned about her increasing difficulty at school since she began third grade 7 weeks ago. Her teachers report that she is easily frustrated and has had difficulty reading and paying attention. She also has had increased impulsivity and more difficulty than usual making and keeping friends. Her biologic mother abused multiple substances before and during pregnancy, and the patient was adopted shortly after birth. The most likely explanation for these findings is in utero exposure to which of the following? A 77-year-old man comes to the physician with his daughter for a follow-up examination to learn the results of neuropsychological testing performed 1 week ago for evaluation of a recent memory loss. Results of the testing indicated cognitive changes consistent with early stages of dementia. Three weeks ago, he was diagnosed with prostate cancer and has shown signs of a depressed mood since then. Twenty years ago, he required treatment in a hospital for major depressive disorder. His symptoms resolved with antidepressant therapy, and he has not taken any psychotropic medication for the past 15 years. She says she is concerned about what the results might be and how her father will handle them. Which of the following is the most appropriate initial physician statement to this patient? C D B D E D A C A B 128 Surgery Systems Immune System Blood & Lymphoreticular System Nervous System & Special Senses Skin & Subcutaneous Tissue Musculoskeletal System Cardiovascular System Respiratory System Gastrointestinal System Renal & Urinary System Female Reproductive System & Breast Male Reproductive System Endocrine System Multisystem Processes & Disorders Social Sciences Medical ethics and jurisprudence Issues related to death and dying and palliative care Physician Task Applying Foundational Science Concepts Diagnosis: Knowledge Pertaining to History, Exam, Diagnostic Studies, & Patient Outcomes Pharmacotherapy, Intervention & Management Site of Care Ambulatory Emergency Department Inpatient Patient Age Birth to 17 18 to 65 66 and older 1%­5% 5%­10% 5%­10% 1%­5% 3%­7% 10%­15% 8%­12% 20%­25% 3%­7% 3%­7% 1%­5% 3%­7% 5%­10% 1%­5% 8%­12% 50%­60% 30%­35% 35%­40% 25%­35% 30%­35% 8%­12% 60%­70% 20%­25% 129 1. A 52-year-old woman with glioblastoma multiforme in the frontal lobe tells her physician that she does not want operative treatment. She is mentally competent and understands that an operation is the only effective treatment of her tumor, and that without an operation she will die. She is afraid of the adverse effects of an operation and says she has lived a long and happy life. Two weeks later, she lapses into a coma, and her husband requests that the operation be carried out. Which of the following is the most appropriate consideration for her physician in deciding whether to operate? Ten years ago, a 60-year-old woman underwent an aortic valve replacement with a porcine heterograft. A 42-year-old woman comes to the emergency department because of a 2-day history of intermittent lower abdominal pain and nausea and vomiting. Initially, the vomitus was food that she had recently eaten, but it is now bilious; there has been no blood in the vomit. Examination shows a distended tympanitic abdomen with diffuse tenderness and no rebound. A 4-year-old boy is brought to the physician by his parents because of a 4-month history of difficulty running and frequent falls. His parents report that his calves have been gradually increasing in size during this period. A 70-year-old man is admitted to the hospital for elective coronary artery bypass grafting. Ten days after admission to the hospital because of acute pancreatitis, a 56-year-old man with alcoholism develops chills and temperatures to 39. A 24-year-old nulligravid woman is brought to the emergency department after a syncopal episode at work.

Fasting serum studies show a total cholesterol concentration of 240 mg/dL and glucose concentration of 182 mg/dL beck depression inventory test questions purchase 300 mg wellbutrin overnight delivery. A 3-year-old girl is brought to the emergency department because of left leg pain after falling at preschool 2 hours ago depression zen buy wellbutrin 300 mg. She has consistently been at the 10th percentile for height and weight since birth mood disorder and alcohol wellbutrin 300 mg without prescription. An x-ray shows a new fracture of the left femur and evidence of previous fracturing bipolar depression bpd wellbutrin 300 mg line. E A D B E B D D A B 137 Health Systems Science Core Domains Health Care Economics and Policy Health Care Structures and Processes High-value Care (including Patient Safety) Informatics Quality Improvement Cross-cutting Domains Evidence-based Practice Leadership and Change Management Patient-centered Care Systems Thinking Teamwork and Communication 8%­12% 13%­17% 23%­27% 8%­12% 13%­17% 18%­22% 8%­12% 18%­22% 28%­32% 18%­22% 138 1 anxiety young living essential oils buy wellbutrin 300mg with amex. An 83-year-old man who is hospitalized following transtibial amputation for treatment of infected diabetic foot ulcers develops pneumonia and sepsis anxiety heart pain buy 300mg wellbutrin. His only living relatives are his sister, who has severe dementia and resides in a local nursing care facility; his niece, who visits him regularly; and his brother, from whom he is estranged and who does not want any involvement in his care. It is most appropriate for which of the following people to make end-of-life care decisions on behalf of this patient? A family physician in a town located more than 20 miles from the nearest hospital chooses to discontinue traveling to hospitals where his patients are admitted to perform the duties of attending physician. A 40-year-old man with type 2 diabetes mellitus asks his physician what the likelihood is for development of peripheral neuropathy if the patient continues to smoke. Which of the following is the most appropriate study design to determine this prognosis? Prior to discharge from the hospital, patients admitted for exacerbations of chronic obstructive pulmonary disease receive smoking cessation counseling. On discharge, the pharmacist educates and provides patients with written materials regarding the use of their medications. Patients also receive a phone call within 72 hours of discharge and a follow-up appointment within one week. Which of the following interventions will have the greatest impact on readmission rates? A senior medical student is working on a quality improvement project with her advisor. The medical student treated a patient with diabetes mellitus who required foot amputation due to advanced infection. The patient had documented neuropathy and was evaluated as an outpatient four times in one year; no foot examinations were documented during these visits. She conducted a structured chart review of patients with diabetes mellitus in the internal medicine resident continuity clinic as a baseline. According to the Plan-Do-Study-Act paradigm, which of the following is the most appropriate subsequent action? D A B D B 142 Emergency Medicine Advanced Clinical Systems* General Principles, including ethics and patient safety Immunologic Disorders Diseases of the Blood Mental Disorders Diseases of the Nervous System Cardiovascular Disorders Diseases of the Respiratory System Nutritional and Digestive Disorders Gynecologic Disorders Renal, Urinary, Male Reproductive Systems Obstetric Disorders Diseases of the Skin Musculoskeletal and Connective Tissue Disorders Endocrine and Metabolic Disorders Physician Task Promoting Health and Health Maintenance Understanding Mechanisms of Disease Establishing a Diagnosis Applying Principles of Management Patient Age Birth to 17 18 to 65 66 and older 1%­5% 1%­5% 5%­10% 1%­5% 10%­15% 15%­20% 10%­15% 10%­15% 1%­5% 5%­10% 1%­5% 1%­5% 5%­10% 5%­10% 1%­5% 5%­10% 25%­35% 45%­55% 5%­10% 60%­65% 15%­20% *A subset of items across the organ systems includes content that focuses on resuscitation/trauma (~15%) and environmental/toxicologic disorders (~15%). A 15-month-old girl is brought to the emergency department after a generalized tonic-clonic seizure at home. The seizure stopped spontaneously after 2 minutes, and she seemed sleepy afterward. Her parents state that yesterday she had a mild runny nose but otherwise has been well. An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest. His pulse is 130/min, respirations are 8/min and shallow, and palpable systolic blood pressure is 60 mm Hg. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line. D A A D B 147 Internal Medicine Advanced Clinical Systems General Principles Immunologic Disorders Diseases of the Blood Mental Disorders Diseases of the Nervous System Cardiovascular Disorders Diseases of the Respiratory System Nutritional and Digestive Disorders Female Reproductive System Renal, Urinary, Male Reproductive Systems Diseases of the Skin Musculoskeletal and Connective Tissue Disorders Endocrine and Metabolic Disorders Physician Task Promoting Health and Health Maintenance Understanding Mechanisms of Disease Establishing a Diagnosis Applying Principles of Management Site of Care Emergency Department Inpatient Patient Age 17 to 65 66 and older 5%­10% 1%­5% 5%­10% 1%­5% 5%­10% 10%­15% 10%­15% 10%­15% 1%­5% 5%­10% 1%­5% 1%­5% 8%­12% 5%­10% 5%­10% 35%­45% 40%­50% 20%­30% 70%­80% 65%­75% 25%­35% 148 1. A previously healthy 67-year-old man is admitted to the hospital because of lethargy, confusion, muscle cramps, and decreased appetite for 7 days. Adenocarcinoma Clear cell carcinoma Mesothelioma Small cell carcinoma Squamous cell carcinoma A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux. Rectal examination shows no masses; test of the stool for occult blood is positive. A 72-year-old woman is brought to the emergency department 1 hour after the sudden onset of right facial droop and weakness of the right arm and leg. One day after undergoing cholecystectomy, a 37-year-old man becomes increasingly tremulous and anxious. Administration of which of the following is the most appropriate next step in management? Fourteen hours after admission to the hospital for treatment of severe hypertension, a 32-year-old woman has stridor. Her pulse is 140/min, respirations are 32/min, and blood pressure is 140/85 mm Hg. D B E C E 152 Comprehensive Basic Science the Comprehensive Basic Science Examination is a general, integrated achievement test covering material typically learned during basic science education, with somewhat more emphasis on second-year courses in medical schools with traditional curricula. Systems General Principles of Foundational Science Biochemistry and molecular biology Biology of cells Human development and genetics Biology of tissue response to disease Pharmacodynamic and pharmacokinetic processes Microbial biology Normal age-related findings and care of the well patient Immune System Blood & Lymphoreticular System Behavioral Health Nervous System & Special Senses Skin & Subcutaneous Tissue Musculoskeletal System Cardiovascular System Respiratory System Gastrointestinal System Renal & Urinary System Pregnancy, Childbirth, & the Puerperium Female Reproductive System & Breast Male Reproductive System Endocrine System Multisystem Processes & Disorders Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. Social Sciences, Including Communication, Medical Ethics, and Death & Dying Physician Task Applying Foundational Science Concepts Diagnosis: Knowledge Pertaining to History, Exam, Diagnostic Studies, & Patient Outcomes Pharmacotherapy, Intervention & Management 15%­20% 1%­5% 5%­10% 1%­5% 5%­10% 1%­5% 5%­10% 5%­10% 5%­10% 5%­10% 5%­10% 1%­5% 1%­5% 1%­5% 5%­10% 5%­10% 5%­10% 1%­5% 50%­60% 20%­30% 5%­15% 153 1. A 16-month-old boy is brought to the physician by his mother for a well-child examination. His mother expresses concern that he did not walk until the age of 14 months, whereas his older sister walked at the age of 10 months. A 77-year-old woman is visited by the home care nurse who notes that the patient is more lethargic than usual. An increase in the serum concentration or activity of which of the following provides the strongest indication that the patient is dehydrated? A 28-year-old woman, gravida 1, para 1, comes to the physician because of progressive fatigue since delivering a male newborn 6 months ago. Pregnancy was complicated during the third trimester by severe bleeding from placenta previa. She required multiple blood transfusions during the cesarean delivery, but she did well after the delivery. A 12-year-old African American boy is brought to the physician by his mother because of a swollen right earlobe for 3 weeks. The mother developed a thick rubbery scar on her abdomen after a cesarean delivery 12 years ago. Physical examination shows a nontender, flesh-colored swelling of the right earlobe. A 5-year-old boy is brought to the physician by his parents because of an 8-month history of difficulty walking. His parents say that he limps when he walks and has a waddling gait; he also has difficulty standing. When getting up from a sitting position, he uses his hands to walk up his thighs and push his body into a standing position. His mother is an only child, but she has an uncle who became bedridden as a child and died of respiratory arrest. This patient most likely has a mutation in the gene coding for which of the following proteins? A 27-year-old man comes to the physician because of pain with urination for 3 days. Physical examination shows no abnormalities except for a clear, watery urethral discharge. A 20-year-old college student develops fever, severe pharyngitis, hepatosplenomegaly, and lymphadenopathy. A 2-year-old boy with Down syndrome is brought to the physician by his mother for a follow-up examination. His blood pressure is increased in the upper extremities and decreased in the lower extremities. Which of the following parental blood types is most likely to cause this condition? A previously healthy 42-year-old woman comes to the emergency department because of progressive shortness of breath and intermittent cough productive of blood-tinged sputum for 10 days. Goodpasture syndrome Hemolytic uremic syndrome Lцffler syndrome Mucocutaneous lymph node syndrome (Kawasaki disease) Granulomatosis with polyangiitis A 10-year-old boy is found to have mild iron deficiency anemia. His mother informs the physician that the family members belong to a religious denomination that does not consume meat. Her son refuses to eat dark green vegetables or to take vitamin pills, stating that they make him feel nauseated. It is most appropriate for the physician to ask the mother which of the following questions next? A 64-year-old man comes to the physician because of a 3-day history of painful rash over his right flank. Physical examination shows clustered lesions in a band-like area over the right flank. An investigator has conducted an experiment to determine whether certain environmental exposure morbidity is eliminated if a person carries a specific allele of three different genes on three separate chromosomes. The frequencies of an individual having the allele for these respective genes are 0. The probability that a randomly selected individual will have all three alleles is closest to which of the following? A health inspector confiscates chickens smuggled into Taiwan from mainland China after she discovers them in the hold of a ship. Testing shows that, although the chickens appear healthy, they are infected with the H5N1 subtype of the influenza A virus. Which of the following is the primary concern for human health from these virus-infected chickens? Adrenocortical adenoma Ectopic corticotropin-releasing hormone producing neoplasm Ectopic corticotropin-secreting neoplasm Pituitary microadenoma Self-administration of synthetic glucocorticoids A 42-year-old woman comes to the physician for a routine health maintenance examination. Fasting serum studies show: Glucose Cholesterol, total Triglycerides C-reactive protein 105 mg/dL 210 mg/dL 185 mg/dL 0. E A C C E E E C D A 160 Comprehensive Clinical Science the Comprehensive Clinical Science Examination is a general, integrated achievement test covering material typically learned during core clinical clerkships. Systems General Principles, Including Normal Age-Related Findings and Care of the Well Patient Immune System Blood & Lymphoreticular System Behavioral Health Nervous System & Special Senses Skin & Subcutaneous Tissue Musculoskeletal System Cardiovascular System Respiratory System Gastrointestinal System Renal & Urinary System Pregnancy, Childbirth, & the Puerperium Female Reproductive System & Breast Male Reproductive System Endocrine System Multisystem Processes & Disorders Biostatistics, Epidemiology/Population Health, & Interpretation of the Medical Lit. Social Sciences, Including Communication, Medical Ethics, and Death & Dying Physician Task Applying Foundational Science Concepts Diagnosis: Knowledge Pertaining to History, Exam, Diagnostic Studies, & Patient Outcomes Pharmacotherapy, Intervention & Management 1%­5% 1%­5% 1%­5% 5%­10% 5%­10% 1%­5% 5%­10% 5%­10% 10%­15% 5%­10% 5%­10% 5%­10% 5%­10% 1%­5% 5%­10% 5%­10% 1%­5% 1%­5% 10%­20% 40%­50% 30%­40% 161 1. It is unlikely that it will directly benefit the study subjects but very likely that it will benefit future patients. There is a risk for short-term minor gastric discomfort but essentially no risk for long-term adverse effects. The investigator concludes that disclosure of the risks may discourage participation in the trial. A 25-year-old man comes to the emergency department because of a 1-month history of fever, chills, nonproductive cough, and progressive shortness of breath; he now becomes short of breath after walking 20 feet. This patient is most likely to have which of the following immunologic abnormalities? A 27-year-old man is brought to the emergency department 20 minutes after his roommate found him unconscious on their bathroom floor. A 15-year-old boy has had pain in the knee since sustaining an injury in a high school football game 6 weeks ago. The high school trainer has been treating him with heat and ultrasound, without significant improvement. A 2-week-old boy is brought to the physician because of a 3-day history of persistent discharge from his eyes. Examination of the eyes shows tarsal inflammation and a thin mucopurulent discharge. Testing of scrapings from the tarsal conjunctivae is positive for Chlamydia trachomatis. A 62-year-old man comes to the physician because of blood in his urine for 24 hours. Abstinence from which of the following is most likely to have prevented this condition? A 21-year-old nulligravid woman who is not using contraception has had irregular menstrual periods since menarche at age 13 years. On pelvic examination, there is copious cervical mucus and slightly enlarged irregular ovaries. A 50-year-old man has a 1-hour history of unremitting chest pressure and "gassiness. Physical examination shows no abnormalities except for a blood pressure of 140/80 mm Hg. A 32-year-old nulligravid woman comes to the physician because of a 20-minute episode of shortness of breath when she awoke this morning. Physical examination shows erythema, swelling, warmth, and tenderness behind the right knee; a cord-like mass can be palpated. A 4030-g (8-lb 14-oz) newborn has internal rotation of the left upper extremity at the shoulder, extension at the elbow, pronation of the forearm, and flexion of the fingers following a low forceps delivery.

Non-contact cooling water - Water that decreases the temperature of an object anxiety medication discount wellbutrin 300 mg with visa, without ever physically touching the object depression diagnosis buy 300mg wellbutrin visa. Nonpoint pollution source- Any unconfined and nondiscrete conveyance from which pollutants are discharged depression legal definition cheap 300mg wellbutrin visa. There is often a concrete structure or retaining wall at this location to protect the end of the discharge pipe and prevent local erosion of the receiving water bank anxiety and depression purchase wellbutrin 300mg free shipping. Point source - Any discernible mood disorder assessment order 300mg wellbutrin visa, confined depression symptoms hallucinations safe wellbutrin 300 mg, and discrete conveyance from which pollutants are, or may be, discharged. Pollutant - Any material in water or wastewater interfering with designated beneficial uses. Potable domestic water - Water that has been treated, or is naturally fit, for drinking, i. Precision - the measure of the degree of agreement among replicate analyses of a sample, usually expressed as the standard deviation. Pretreatment - the removal of material such as, gross solids, grit, grease, metals, toxicants. This is usually done by the industrial user of the water, but can also refer to the initial treatment processes of a sewage treatment plant. Process line discharge - the disposal of anything used in, or resulting from, a manufacturing process. Process water - Water used in industry to perform a variety of functions, or as an actual product ingredient. Receiving waters - Natural or man-made water systems into which stormwaters, or other wastewaters, are discharged for disposal. Rinse water - Water that cleans or reduces the temperature of an object through actual physical contact with the object. Septic Tank - A rectangular tank divided into two compartments for the treatment of residential (most common) wastewaters by anaerobic digestion, floatation, and sedimentation. Partially treated septic tank effluent is then discharged to a leaching field for additional treatment in the soil system and for final disposal. Sewer - A pipe or conduit generally closed, but normally not flowing full, for carrying wastewater. Sewerage - System of piping, with appurtenances, for collecting and conveying wastewaters from source to discharge. Storm drainage discharge - Flow from a storm drain that is discharged to a receiving water. Stormwater - Water resulting from precipitation which does not percolate into the soil; it runs freely from the surface, or is captured by storm drainage, combined sewer, and to a limited degree, by sanitary sewer facilities. Surfactants - Surface-active agent and common component in detergents which affects the surface tension of water and can cause foaming. Total solids - the entire quantity of solids in the liquid flow or volume including the dissolved and particulate (suspended, floatable and settleable) fractions. Toxicity - the degree to which a pollutant causes physiological harm to the health of an organism. From a regulatory standpoint, this usually refers to metal concentrations that can cause toxicity at trace concentrations. Turbidity - A measure of the lack of clarity in the water usually caused by suspended particulate matter. During wet weather, it is comprised of surface runoff from an urban drainage area. During dry weather, it may be comprised of many baseflow components, both uncontaminated and contaminated. Urban stormwater runoff - A discharge from a stormwater drainage system occurring during wet weather, comprised of surface runoff from an urban drainage area. Wet-weather flow - Surface runoff due to precipitation (rain and snow) which may introduce contaminants into storm drainage systems. Para obtener mбs informaciуn pуngase en contacto con: Oficina de los derechos de autor, marcas comerciales, acuerdos de licencia y regalнas, Agencia de Educaciуn de Texas, 1701 N. La investigaciуn muestra que es improbable que un niсo que no aprende conceptos bбsicos de lectura a una temprana edad los aprenda en absoluto. Cualquier niсo que no aprenda a leer temprano y bien tendrб problemas para dominar otras habilidades y conocimientos y es poco probable que prospere en la escuela o la vida". Esta historia incluye un foco en la identificaciуn y la intervenciуn temprana para los niсos que tienen dificultades para leer. El manual fue actualizado otra vez en el aсo 2001 y fue llamado El Manual sobre la dislexia: procedimientos sobre la dislexia y trastornos relacionados. En el verano de 2010, se presentу la necesidad para una actualizaciуn del manual para incluir la nueva legislaciуn e investigaciуn adicional. El Manual sobre la dislexia ­ modificado en el 2014: procedimientos sobre la dislexia y trastornos relacionados (El Manual sobre la dislexia) es el resultado de la nueva legislaciуn aprobada en las sesiones legislativas 82 y 83. El Manual sobre la dislexia les provee directrices a los distritos escolares que deben seguir como identificar y ofrecer servicios para los estudiantes con dislexia. El Apйndice D de este manual contiene informaciуn para los 20 centros de servicios regionales de educaciуn. Sandy Maddox, Geraldine "Tincy" Miller, Gina Mitchell, Sylvia Portnoy, Michelle Reeves, Javalette Rogers, Dr. Ademбs, les agradecemos a los siguientes investigadores por la revisiуn de este manual: Dr. Joe Torgesen La Agencia de Educaciуn de Texas Monica Martinez Comisionado asociado, normas y programas Shelly Ramos Director de administraciуn, divisiуn de estudios Kelly Callaway Director de la fundaciуn de educaciуn K ­ 12 Karin Miller Coordinador de lengua/lectura en inglйs en todo el estado 5 Prefacio En el estado de Texas, los estudiantes que siguen teniendo problemas para leer a pesar de la instrucciуn apropiada o intensificada, reciben sistemas organizados para el apoyo de la lectura. Algunos estudiantes tienen problemas al aprender a leer mientras que otros no tienen problemas hasta estar en grados mayores, incluso en el nivel postsecundario. Aquн enfrentan demandas del idioma mбs complejas (por ejemplo: libros de lectura, textos acadйmicos y otros materiales impresos). La dislexia se encuentra en todas las poblaciones de estudiante y en todos los idiomas. En Texas, se llevу a cabo una evaluaciуn de la dislexia desde jardнn hasta el 12є grado. El propуsito de El Manual sobre la dislexia es proporcionar los procedimientos para los distritos escolares, escuelas subvencionadas, campus, maestros, estudiantes y padres/tutores para la identificaciуn temprana, instrucciуn y acomodos para los estudiantes con dislexia. Este manual se utilizarб por los distritos y las escuelas subvencionadas a medida que desarrollan sus procedimientos escritos con respecto a los estudiantes con dislexia. Tambiйn sirve como un recurso para los programas de preparaciуn para educadores y otras entidades que buscan orientaciуn para ayudar a los estudiantes con dislexia. Finalmente, la ley de rehabilitaciуn de 1973, §504, establece procedimientos y normas de valoraciуn y evaluaciуn para estudiantes (34 C. Este manual refleja la ley actual, asн como la acciуn legislativa de las sesiones 82 y 83 de la legislatura de Texas y reemplaza todas las ediciones anteriores del manual. Enseсanza para estudiantes con dislexia El Manual sobre la dislexia tiene nueve apйndices: A. Fuentes de leyes y normas para la identificaciуn y enseсanza de dislexia Estatutos estatales relacionados con la dislexia Preguntas y respuestas Contactos para informaciуn adicional Tйrminos asociados Bibliografнa Estudiantes con discapacidades preparбndose para educaciуn postsecundaria: conozca sus derechos y responsabilidades H. Historia de la ley de dislexia 7 Estб pбgina se ha dejado en blanco intencionalmente 8 I. Definiciones y caracterнsticas de la dislexia El estudiante que tiene problemas para leer y deletrear a menudo intriga a los maestros y los padres. El estudiante muestra la capacidad de aprender sin material impreso y recibe la misma instrucciуn en el aula que beneficia a la mayorнa de los niсos; sin embargo, el estudiante continъa teniendo problemas con todas o algunas de las tantas facetas de la lectura y deletreo. Se caracteriza por dificultades con el reconocimiento de palabras exactas y/o fluidas y habilidades de deletreo y decodificaciуn pobres. Estas dificultades resultan tнpicamente de un dйficit en el componente fonolуgico de la lengua que es a menudo inesperada en relaciуn con otras habilidades cognitivas y la provisiуn de instrucciуn efectiva en el aula. Las consecuencias secundarias pueden incluir problemas en la comprensiуn de lectura y experiencia de lectura reducida que puede impedir el crecimiento del conocimiento de vocabulario. Las consecuencias pueden incluir dificultades en la lectura de comprensiуn y expresiуn escrita. Estas dificultades en la conciencia fonolуgica son inesperadas para la edad y nivel educativo del estudiante y no son principalmente el resultado de factores de diferencia de lenguaje. Las siguientes son las principales caracterнsticas de lectura/deletreo de la dislexia: · Dificultad para leer palabras aisladas · Dificultad para descifrar exactamente palabras desconocidas · Dificultades con la lectura oral (lenta, imprecisa o forzada) · Dificultad para deletrear Es importante indicar que las personas demuestran diferencias en el grado de deterioro. Las caracterнsticas de lectura/deletreo mбs a menudo estбn asociadas con lo siguiente: · Segmentar, mezclar y manipular los sonidos en palabras (conciencia fonйmica) · Aprender los nombres de las letras y sus sonidos asociados · Saber informaciуn sobre sonidos y palabras de memoria (memoria fonolуgica) · Recordar los nombres de objetos familiares, colores o letras del alfabeto rбpidamente (denominaciуn rбpida) 9 Las consecuencias de la dislexia pueden incluir lo siguiente: · Dificultad variable en aspectos de la comprensiуn de lectura · Dificultad variable en aspectos de la lengua escrita · Crecimiento de vocabulario limitado debido a las experiencias de lectura reducida Fuentes de las caracterнsticas y consecuencias de la dislexia Branum-Martin, L. La Asociaciуn Internacional de Dislexia, Comitй de estбndares y prбcticas profesionales. Conectando la investigaciуn y la prбctica Se estбn llevando a cabo nuevas investigaciones para entender sobre la dislexia como un trastorno del neurodesarrollo. La investigaciуn futura le ayudarб a aprender mбs sobre el dйficit de la conciencia fonolуgica y cуmo este dйficit interactъa con otros factores de riesgo relacionados con la dislexia. La investigaciуn tambiйn se centra en la causa del desarrollo de anormalidades neuronales y cуmo йstos predicen la respuesta al tratamiento. Factores de riesgo comunes asociados con la dislexia Si los siguientes comportamientos son inesperados para la edad, el nivel educativo o las habilidades cognitivas de un individuo, pueden ser factores de riesgo asociados con la dislexia. Un estudiante con dislexia generalmente exhibe varios de estos comportamientos que persisten en el tiempo e interfieren con su aprendizaje. Una historia familiar de dislexia puede estar presente; de hecho, los estudios recientes revelan que el espectro entero de discapacidad de lectura estб determinado fuertemente por las predisposiciones genйticas (aptitudes heredadas) (Olson, Keenan, Byrne, y Samuelsson, 2014). Preescolar Retraso en aprender a hablar Dificultad con rimas Dificultad para pronunciar palabras (por ejemplo: "pusgetti" para "spaghetti," "mawn lower" para "lawn mower") Memoria auditiva deficiente de rimas y cantos Dificultad para agregar nuevo vocabulario 10 Incapacidad para recordar la palabra correcta (recordar palabras) Dificultad para aprender y nombrar las letras y nъmeros y recordando las letras de su nombre Aversiуn a cosas impresas (por ejemplo: no disfruta seguir la escritura si el libro se lee en voz alta) Jardнn de infantes y primer grado Dificultad para separar palabras en partes mбs pequeсas (sнlabas) (por ejemplo: "baseball" puede separarse en "base" " ball" o "napkin" puede separarse en "nap" "kin") Dificultad para identificar y manipular sonidos en sнlabas (por ejemplo: "man" deletreado como /m/ // /n/) Dificultad para recordar los nombres de las letras y recordar sus sonidos correspondientes Dificultad para descifrar palabras sueltas (leer palabras aisladas) Dificultad para deletrear palabras de la manera en que suenan (fonйticamente) o recordar las secuencias de la letra en palabras muy comunes que se ven impresa (por ejemplo: "sed" para "said") Segundo y tercer grado Muchos de los comportamientos descritos anteriormente siguen siendo problemбticos junto con los siguientes: Dificultad para reconocer palabras comunes (por ejemplo: "to," "said," "been") Dificultad para descifrar palabras sueltas Dificultad para recordar los sonidos correctos para las letras y patrones de letras al leer Dificultad para conectar los sonidos del lenguaje con letra apropiada o combinaciones de letras y omitir letras en palabras al deletrear (por ejemplo: "after" spelled "eftr") Dificultad para leer con fluidez (por ejemplo: lento, inexacto, o sin expresiуn) Dificultad para descifrar palabras desconocidas en oraciones usando el conocimiento de la fonйtica Dependencia en pistas de fotos, historias o adivina palabras Dificultad con la expresiуn escrita Cuarto a sexto grado Muchos de los comportamientos descritos anteriormente siguen siendo problemбticos junto con los siguientes: Dificultad para leer en voz alta (por ejemplo: miedo para leer en voz alta frente a compaсeros de clase) Evitar leer (por ejemplo: particularmente por placer) Adquisiciуn de menos vocabulario debido a lectura independiente menor El uso de palabras menos complicadas en la escritura que son mбs fбciles de deletrear que palabras mбs apropiadas (por ejemplo: "grande" en lugar de "enorme") Dependencia en escuchar mбs en vez de leer para comprender Escuela intermedia y secundaria Muchos de los comportamientos descritos anteriormente siguen siendo problemбticos junto con los siguientes: Dificultad con el volumen de lectura y trabajo escrito Frustraciуn con la cantidad de tiempo requerido y la energнa puesta para la lectura Dificultad con asignaciones escritas Tendencia a evitar leer (particularmente por placer) Dificultad para aprender una lengua extranjera 11 Educaciуn postsecundaria Algunos estudiantes no serбn identificados como individuos con dislexia antes de comenzar la universidad. Los primeros aсos de dificultades para leer evolucionan en fluidez de lectura lenta, dificultosa. Muchos estudiantes experimentarбn extrema frustraciуn y fatiga debido a las crecientes demandas de lectura como resultado de la dislexia. Al hacer un diagnуstico de dislexia, es esencial evaluar la historia de lectura, predisposiciуn familiar/genйtica e historia de evaluaciуn de un estudiante. Muchas de las conductas descritas anteriormente pueden seguir siendo problemбticas junto con los siguientes: Dificultad para pronunciar los nombres de personas y lugares o partes de palabras Dificultad para recordar nombres de personas y lugares Dificultad para recordar palabras Dificultad con vocabulario hablado Dificultad para completar las demandas de lectura para mъltiples requisitos del curso Dificultad para tomar notas Dificultades con la producciуn escrita Dificultad para recordar las secuencias (por ejemplo: fуrmulas matemбticas o cientнficas) Apйndice G: Estudiantes con discapacidades preparбndose para educaciуn postsecundaria: conozca sus derechos y responsabilidades se ha incluido para obtener informaciуn adicional. Ya que la dislexia es una discapacidad neurolуgica, basada en el lenguaje que persiste e interfiere con el aprendizaje de un individuo, es fundamental que la identificaciуn e intervenciуn ocurran tan pronto como sea posible. Dificultades acadйmicas y otras condiciones asociadas Los comportamientos en las secciones anteriores representan dificultades comunes que pueden exhibir los estudiantes con dislexia. Ademбs, los estudiantes con dislexia pueden tener problemas en la expresiуn escrita, comprensiуn de lectura y matemбticas, asн como otros que complican las condiciones y/o comportamientos. Ademбs de los problemas acadйmicos, algunos estudiantes con dislexia pueden presentar otras condiciones y/o comportamientos complejos. Algunos, aunque no todos, los estudiantes con dislexia tambiйn pueden experimentar sнntomas tales como ansiedad, ira, depresiуn, falta de motivaciуn o baja autoestima. En tales casos, es necesario proporcionar servicios de instrucciуn/referencia apropiados. Estas condiciones adicionales pueden tener un impacto significativo sobre la efectividad de la instrucciуn proporcionada a estudiantes con dislexia. La motivaciуn en particular, ha demostrado ser crнtica para el йxito o fracaso de prбcticas educacionales. En cuanto a la motivaciуn, Torgesen dice (segъn lo citado en Sedita, 2011), "incluso las tйcnicas educacionales tйcnicamente sуlidas tienen pocas probabilidades de tener йxito si no podemos asegurar que, la mayorнa del tiempo, los estudiantes estбn comprometidos y motivados para entender lo que leen" (p. Por lo tanto, deben considerarse todos los factores que pueden afectar el aprendizaje al identificar y proporcionar instrucciуn para los estudiantes con dislexia. Los educadores son responsables de proveer un ambiente de afirmaciуn que motiva y compromete a los estudiantes con dislexia y condiciones complicadas. Journal of the American Academy of Child and Adolescent Psychiatry 41(5), 530­537. Procedimientos para la evaluaciуn e identificaciуn de estudiantes con dislexia "Las investigaciones cientнficas demuestran que los niсos que aprenden a leer a una edad temprana tienen mayor posibilidad de tener йxito en los aсos sucesivos y aquellos que se atrasan frecuentemente se quedan retrasados en su desarrollo acadйmico" -Snow, Burns, y Griffin, 1998 La identificaciуn temprana de los estudiantes con dislexia, asн como el programa de intervenciуn temprana correspondiente para estos estudiantes tendrбn implicaciones significativas para su futuro йxito acadйmico. En el libro Straight Talk About Reading [Hablemos claro sobre la lectura], Hall y Moats (1999) manifiesta lo siguiente: · · · "La identificaciуn temprana es fundamental porque cuanto antes se hace la intervenciуn, mбs fбcil es para remediar". La investigaciуn continъa apoyando la necesidad de la identificaciуn y evaluaciуn temprana (Birsh, 2011; Sousa, 2005; Nevills & Wolfe, 2009). El rбpido crecimiento del cerebro y su capacidad de respuesta a la instrucciуn en la escuela primaria hace que el tiempo desde el nacimiento hasta la edad de ocho aсos sea un perнodo crнtico para el desarrollo de la alfabetizaciуn (Nevills & Wolfe, 2009). Las caracterнsticas asociadas con dificultades de lectura estбn conectadas a la lengua hablada. Las dificultades en los niсos pequeсos pueden ser evaluadas a travйs de las proyecciones de la conciencia fonйmica y otras habilidades fonolуgicas (Sousa, 2005). Teniendo presente la informaciуn antes mencionada, es importante que el distrito escolar no retrase los procesos de identificaciуn e intervenciуn hasta el segundo o tercer grado para los estudiantes que se sospecha que tienen dislexia. Este proceso de identificaciуn debe ser una evaluaciуn individualizada en lugar de una proyecciуn. La identificaciуn y el proceso de intervenciуn para la dislexia pueden ser multifacйticos. Sin embargo, en Texas, la intervenciуn e identificaciуn de dislexia suele hacerse a travйs de la educaciуn general en lugar de educaciуn especial. De hecho, la ley estatal requiere el uso de evaluaciones de lectura temprana que se basan en evidencia sustancial de las mejores prбcticas. Si se eligen cuidadosamente, estas evaluaciones pueden proporcionar informaciуn crucial sobre el aprendizaje del estudiante y pueden proporcionar una base para el modelo de intervenciуn en niveles. A travйs del proceso de intervenciуn en niveles, las escuelas pueden documentar las dificultades de aprendizaje de los estudiantes, proporcionar evaluaciуn continua y monitorear el progreso del logro en la lectura para los estudiantes en riesgo de dislexia u otras dificultades de lectura. La intervenciуn temprana se acentъa aъn mбs como resultado de la investigaciуn mediante neuroimagen. Diehl, Frost, Mencl y Pugh (2011) abordan la necesidad de determinar el papel que juegan los dйficits en la conciencia fonolуgica y conciencia fonйmica en la adquisiciуn de la lectura, asн mejorando nuestra metodologнa para la intervenciуn temprana.

Target ing only presenting problems and symptoms does not provide individuals with an oppor tunity to see their own resourcefulness in managing very stressful and difficult experi ences anxiety urinary frequency wellbutrin 300 mg. It is important for providers to engage in interventions using a balanced approach that targets the strengths clients have "Trauma-informed care recognizes symptoms as originating from adaptations to the traumatic event(s) or context depression symptoms how long order 300mg wellbutrin fast delivery. Validat ing resilience is important even when past coping behaviors are now causing prob lems mood disorder 6 gameplay discount wellbutrin 300 mg on-line. What characteristics have helped you manage these experiences and the challenges that they have created in your life? A strengths-based depression definition with reference cheap wellbutrin 300mg online, resilience-minded approach lets trauma survi vors begin to acknowledge and appreciate their fortitude and the behaviors that help them survive bipolar depression laziness purchase 300mg wellbutrin amex. Some theoretical models that use skillbuilding strategies base the value of this ap proach on a deficit perspective; they assume that some individuals lack the necessary tools to manage specific situations and anxiety 4 months postpartum generic wellbutrin 300mg fast delivery, because of this deficiency, they encounter problems that others with effective skills would not experi ence. This type of perspective further assumes that, to recover, these individuals must learn new coping skills and behavior. Pre vention, mental health, and substance abuse treatment services should include teaching clients about how trauma can affect their lives; these services should also focus on developing self-care skills, coping strategies, supportive networks, and a sense of competence. Agencies need to embrace specific strategies across each level of the organization to create trauma-informed services; this begins with staff education on the impact of trauma among clients. Other agency strategies that reflect a trauma-informed infrastructure in clude, but are not limited to: · Universal screening and assessment proce dures for trauma. Develop Strategies To Address Secondary Trauma and Promote Self-Care Secondary trauma is a normal occupational hazard for mental health and substance abuse professionals, particularly those who serve populations that are likely to include survivors of trauma (Figley, 1995; Klinic Community Health Centre, 2008). Behavioral health staff members who experience secondary trauma present a range of traumatic stress reactions 29 Trauma-Informed Care in Behavioral Health Services and effects from providing services focused on trauma or listening to clients recount traumatic experiences. The range of reactions that manifest with sec ondary trauma can be, but are not necessarily, similar to the reactions presented by clients who have experienced primary trauma. Symp toms of secondary trauma can produce varying levels of difficulty, impairment, or distress in daily functioning; these may or may not meet diagnostic thresholds for acute stress, posttraumatic stress, or adjustment, anxiety, or mood disorders (Bober & Regehr, 2006). Symptoms may include physical or psycholog ical reactions to traumatic memories clients have shared; avoidance behaviors during client interactions or when recalling emotional con tent in supervision; numbness, limited emo tional expression, or diminished affect; somatic complaints; heightened arousal, including in somnia; negative thinking or depressed mood; and detachment from family, friends, and oth er supports (Maschi & Brown, 2010). Working daily with individuals who have been traumatized can be a burden for counselors and other behavioral health service providers, but all too often, they blame the symptoms resulting from that burden on other stressors at work or at home. Only in the past 2 decades have literature and trainings begun paying attention to secondary trauma or compassion fatigue; even so, agencies often do not trans late this knowledge into routine prevention practices. Counselors and other staff members may find it difficult to engage in activities that could ward off secondary trauma due to time constraints, workload, lack of agency re sources, and/or an organizational culture that disapproves of help-seeking or provides inade quate staff support. The demands of providing care to trauma survivors cannot be ignored, lest the provider become increasingly impaired and less effective. Counselors with unacknowledged secondary trauma can cause harm to clients via poorly enforced bounda ries, missed appointments, or even abandon ment of clients and their needs (Pearlman & Saakvitne, 1995). The impact first creates the largest wave, which is followed by ever-expanding, but less intense, ripples. Likewise, the influence of a given trauma can be broad, but generally, its effects are less intense for individuals further removed from the trauma; eventually, its im pact dissipates all around. For trauma survivors, the impact of trauma can be far-reaching and can affect life areas and relationships long after the trauma occurred. This analogy can also broadly describe the recovery process for indi viduals who have experienced trauma and for those who have the privilege of hearing their stories. As survivors reveal their trauma-related experiences and struggles to a counselor or another caregiver, the trauma becomes a shared experience, although it is not likely to be as intense for the caregiver as it was for the individual who experienced the trauma. Seeking professional support will enable you to understand your own responses to clients and to work with them more effectively. Ongoing professional training can improve your belief in your abilities to assist clients in their recoveries. Obtaining treatment can help you manage specific problems and become better able to provide good treatment to your clients. A healthy, balanced lifestyle can make you more resilient in managing any difficult circumstances you may face. Clearly separating your personal and work life allows time to rejuvenate from stresses inherent in being a professional caregiver. In agencies and among individual providers, it is key for the culture to promote acceptability, accessibility, and accountability in seeking help, accessing support and supervision, and engaging in self-care behaviors in and outside of the agency or office. Agencies should in volve staff members who work with trauma in developing informal and formal agency prac tices and procedures to prevent or address sec ondary trauma. Even though a number of community-based agencies face fiscal con straints, prevention strategies for secondary trauma can be intertwined with the current infrastructure. However, they often possess a history of un predictable symptoms and symptom intensity that reinforces an underlying belief that recov ery is not possible. On one hand, clients are looking for a message that they can be cured, while on the other hand, they have serious doubts about the likely success of any intervention. The idea of liv ing with more discomfort as they address the past or as they experiment with alternative ways of dealing with trauma-related symptoms or consequences is not an appealing prospect, and it typically elicits fear. Clients may inter pret the uncomfortable feelings as dangerous or unsafe even in an environment and rela tionship that is safe and supportive. First, maintain consistency in delivering services, promoting and providing safety for clients, and showing respect and compassion within the client­ provider relationship. Does it mean that clients stop hav ing nightmares or being reminded, by cues, of past trauma? When clients who have experi enced trauma enter into a helping relationship 31 Trauma-Informed Care in Behavioral Health Services to be aware of, and circumvent, practices that could retraumatize clients. This attitude also involves viewing clients as competent to make changes that will allow them to deal with trauma-related challenges, providing opportu nities for them to practice dealing with diffi cult situations, and normalizing discomfort or difficult emotions and framing these as man ageable rather than dangerous. If you convey this attitude consistently to your clients, they will begin to understand that discomfort is not a signal to avoid, but a sign to engage-and that behavioral, cognitive, and emotional re sponses to cues associated with previous trau mas are a normal part of the recovery process. Cli ents can also benefit from interacting with others who are further along in their recovery from trauma. Time spent with peer support staff or sharing stories with other trauma sur vivors who are well on their way to recovery is invaluable-it sends a powerful message that recovery is achievable, that there is no shame in being a trauma survivor, and that there is a future beyond the trauma. As you pro ceed, be aware of the wide-ranging responses to trauma that occur not only across racially and ethnically diverse groups but also within specific communities, families, and individuals. Counselors, prevention specialists, other be havioral health workers, supervisors, and or ganizations all need to develop skills to create an environment that is responsive to the unique attributes and experiences of each cli ent. Single, multiple, or chronic exposures to traumatic events, as well as the emotional, cognitive, behavioral, and spiritual responses to trauma, need to be understood within a socialecological framework that recognizes the many ingredients prior to , during, and after traumatic experiences that set the stage for recovery. It is normal to experience such events across the lifespan; often, individuals, families, and com munities respond to them with resilience. This chapter explores several main elements that influence why people respond differ ently to trauma. Using the social-ecological model outlined in Part 1, Chapter 1, this chapter explores some of the contextual and systemic dynamics that influence individual and community perceptions of trauma and its impact. The three main foci are: types of trauma, objective and subjective characteristics of trauma, and individual and sociocultural features that serve as risk or pro tective factors. It does not cover every conceivable trauma that an individual, group, or community may encounter. Specific traumas are re viewed only once, even when they could fit in multiple categories of trauma. The intent is to give a broad perspective of the various categories and types of trauma to behavioral health workers who wish to be trauma in formed. Nat ural traumatic experiences can directly affect a small number of people, such as a tree falling on a car during a rainstorm, or many people and communities, as with a hurricane. Although multiple factors contribute to the severity of a natural or human-caused trauma, traumas perceived as intentionally harmful often make the event more traumatic for people and communities. Intentional Acts Arson Terrorism Sexual assault and abuse Homicides or suicides Mob violence or rioting Physical abuse and neglect Stabbing or shooting Warfare Domestic violence Poisoned water supply Human trafficking School violence Torture Home invasion Bank robbery Genocide Medical or food tampering How survivors of natural trauma respond to the experience often depends on the degree of devastation, the extent of individual and community losses, and the amount of time it takes to reestablish daily routines, activities, and services. The amount, accessibil ity, and duration of relief services can signifi cantly influence the duration of traumatic stress reactions as well as the recovery process. Alongside the disruption of daily routines, the presence of community members or outsiders in affected areas may add significant stress or create traumatic experiences in and of them selves. Examples include the threat of others stealing what remains of personal property, restrictions on travel or access to property or living quarters, disruption of privacy within shelters, media attention, and subsequent ex posure to repetitive images reflecting the dev astation. They are ei ther intentional, such as a convenience store robbery at gunpoint, or unintentional, such as the technological accident of a bridge collapse (as occurred in Minneapolis, Minnesota, in 2007; U. Survi vors of an unintentionally human-caused traumatic event may feel angry and frustrated because of the lack of protection or care of fered by the responsible party or government, particularly if there has been a perceived act of omission. Families and community members experienced significant grief and traumatic stress after the disas ter. Yet today, Greensburg is rebuilding with a focus on being "green"-that is, environmentally responsible-from design to construction and all the way through demolition. This town has the highest number of Leadership in Energy and Environmental Design­certified buildings in the world. Individual trauma An individual trauma refers to an event that only occurs to one person. Although the trauma directly affects just one individual, others who know the person and/or are aware of the trauma will likely experience emotional repercussions from the event(s) as well, such as recounting what they said to the person before the event, reacting in disbelief, or thinking that it could just as easily have hap pened to them, too. Survivors of individual trauma may not receive the environmental support and concern that members of collectively traumatized groups and communities receive. They are less likely to reveal their traumas or to receive validation of their experiences. Some survivors of individual traumas, especially those who have kept the trauma secret, may not receive needed comfort and Individual, Group, Community, and Mass Traumas In recognizing the role of trauma and under standing responses to it, consider whether the trauma primarily affected an individual and perhaps his or her family. This context can have significant im plications for whether (and how) people expe rience shame as a result of the trauma, the kinds of support and compassion they receive, whether their experiences are normalized or diminished by others, and even the kinds of services they are offered to help them recover and cope. Strategies that focus on reexperiencing the trauma, retrieving feelings related to the trauma, and bringing past experiences to the forefront should only be implement ed if trauma-specific treatment planning and services are available. Physical injuries Physical injuries are among the most prevalent individual traumas. Sudden, unexpected, adverse healthrelated events can lead to extensive psycholog ical trauma for patients and their families. Studies con sistently connect injuries and substance use (Gentilello, Ebel, Wickizer, Salkever, & Rivara, 2005); nearly 50 percent of patients admitted to trauma centers have injuries at tributable to alcohol abuse and dependence (Gentilello et al. Clients who have sustained serious injuries in car crashes, fires, stabbings, shootings, falls, and other events have an increased likelihood of developing trauma-related mental disorders. Group trauma the term "group trauma" refers to traumatic experiences that affect a particular group of people. These groups often share a common identity and history, as well as similar activities and concerns. Some examples of group trauma include crews and their families who lose members from a commercial fishing accident, a gang whose members experience multiple deaths and inju ries, teams of firefighters who lose members in a roof collapse, responders who attempt to save flood victims, and military service mem bers in a specific theater of operation. Survivors of group trauma can have different experiences and responses than survivors of individual or mass traumas. Survivors of group trauma, such as military service members and first responders, are likely to experience re peated trauma. They tend to keep the trauma experiences within the group, feeling that oth ers outside the group will not understand; group outsiders are generally viewed as intrud ers. Members may encourage others in the group to shut down emotionally and repress their traumatic experiences-and there are some occupational roles that necessitate the 38 repression of reactions to complete a mission or to be attentive to the needs at hand. Group members may not want to seek help and may discourage others from doing so out of fear that it may shame the entire group. In this environment, members may see it as a viola tion of group confidentiality when a member seeks assistance outside the group, such as by going to a counselor. Group members who have had traumatic experiences in the past may not actively sup port traumatized colleagues for fear that ac knowledging the trauma will increase the risk of repressed trauma-related emotions surfac ing. However, groups with adequate resources for helping group members can develop a stronger and more supportive environment for handling subsequent traumas. These main group features influence the course of shortand long-term adjustments, including the development of traumatic stress symptoms associated with mental and substance use disorders. Certain occupational groups are at greater risk of experiencing trauma-particularly multiple traumas. First responders First responders are usually emergency medi cal technicians, disaster management person nel, police officers, rescue workers, medical and behavioral health professionals, journalists, and volunteers from various backgrounds. Stressors associated with the kinds of traumatic events and/or disasters first responders are likely to experience include Part 1, Chapter 2-Trauma Awareness exposure to toxic agents, feeling responsible for the lives of others, witnessing catastrophic devastation, potential exposure to gruesome images, observing human and animal suffering and/or death, working beyond physical ex haustion, and the external and internal pres sure of working against the clock. Trauma affecting communities and cultures Trauma that affects communities and cultures covers a broad range of violence and atrocities that erode the sense of safety within a given community, including neighborhoods, schools, towns, and reservations. It may in volve violence in the form of physical or sexual assaults, hate crimes, robberies, workplace or gang-related violence, threats, shootings, or stabbings-for example, the school shooting at Virginia Polytechnic Institute and State University in 2007. It also includes actions that attempt to dismantle systemic cultural practices, resources, and identities, such as making boarding school attendance mandato ry for Native American children or placing them in non-Native foster homes. Cultural and/or community-based trauma can also oc cur via indifference or limited responsiveness to specific communities or cultures that are facing a potential catastrophe. Cultural trau mas are events that, whether intentionally or not, erode the heritage of a culture-as with prejudice, disenfranchisement, and health inequities. Military service members Military personnel are likely to experience numerous stressors associated with trauma. So too, service members who anticipate de ployment or redeployment may exhibit psy chological symptoms associated with traumatic stress. Some stressors that military service members may encounter include work ing while physically exhausted, exposure to gunfire, seeing or knowing someone who has been injured or killed, traveling in areas known for roadside bombs and rockets, ex tended hypervigilance, fear of being struck by an improvised explosive device, and so forth. Never in the millen nium of our tradition have we thought it possible for the water to die, but it is true. The oil spill destroyed more than economic resources; it shook the core cultural foundation of Native life.

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References

• Eichhorst ST, Krammer PH: Derangement of apoptosis in cancer. Lancet 358: 345, 2001.
• Rohr LR: Incidental adenocarcinoma in transurethral resections of the prostate. Partial versus complete microscopic examination, Am J Surg Pathol 11(1):53n58, 1987.
• Yang L, et al. Dopamine D1 receptor agonists inhibit lung metastasis of breast cancer reducing cancer stemness. Eur J Pharmacol. 2019;859:172499.
• Naftifine Study Group. Naftifine gel in the treatment of tinea pedis: two double-blind, multicenter studies. Cutis 1991;48:85-8.
• Brenner DW, Schellhammer PF: Upper tract urothelial malignancy after cyclophosphamide therapy: a case report and literature review, J Urol 137(6):1226n1227, 1987.
• Sonoo M, Tsai-Shozawa Y, Aoki M, et al. N18 in median somatosensory evoked potentials: a new indicator of medullary function useful for the diagnosis of brain death. J Neurol Neurosurg Psychiatry. 199;67(3):374-378.