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By P. Aila. Wartburg College.

The hallmark of nonfebrile seizures is an alteration of motor or sensory function or of awareness in a child who does not have a fever cheap levitra soft 20mg with visa. However buy cheap levitra soft 20mg on line, fevers may trigger nonfebrile seizures by lowering the child’s seizure threshold order 20 mg levitra soft otc. Since the physician is unlikely to treat a child after either a first febrile seizure or a nonfebrile seizure triggered by fever purchase 20 mg levitra soft, the distinction between the two after a first episode is neither possible nor important buy discount levitra soft 20mg on line. Practice parameters have also been issued for the evaluation of nonfebrile seizures in children. Evaluation after a First Nonfebrile Seizure Recommendations for the evaluation of a child after a first nonfebrile seizure have recently been published by the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. A careful history, phy- sical and neurological examination should always be performed. As discussed above, a careful history can, with great reliability, differentiate a seizure from other parox- ysmal events. Routine laboratory screening with blood counts, glucose, electrolytes, calcium, etc. But not by author Blood studies Based on history Imaging Sometimes based Unless on history emergency preferable Counseling of parents X Evaluation of a Child with Seizure 59 clinical findings make the physician suspicious of an ongoing or underlying process. Magnetic resonance imaging (MRI) is always preferable to computerized axial tomography (CT scan). Although MRIs are more sensitive, they are rarely rapidly available or necessary after a first episode. If the child has a ‘‘high risk’’ condition such as recent trauma with other neurological findings, sickle cell disease, or a bleeding disorder or if a focal seizure occurred in a child less than 33 months of age, an emergent CT scan may be indicated. The Subcommittee also recommends an EEG as part of the initial evaluation of a nonfebrile seizure ‘‘to determine the epilepsy syndrome, determine the need for imaging, and for predicting the prognosis. He believes that these factors are unimportant after a first seizure since they do not reliably diagnose a syndrome nor predict prognosis. Thus, the emergency room evaluation for both febrile seizures and nonfebrile seizures need only be minimal. The EEGs are not needed after a febrile seizure, and probably will not be help- ful after a nonfebrile seizure. In every child a good history and physical as well as neurological examination are mandatory. The use of testing should be reserved for the unusual child with a suspicious history or physical examination. Management after a First Episode Although the guidelines for the evaluation of febrile and nonfebrile seizure differ, there is general agreement that no medication is needed after the first seizure of either type. However, a discussion and explanation of what happened and its meaning are always needed to calm the parent’s fears and misconceptions. Most first seizures will not recur with or without medication and this should be emphasized. Generalized tonic–clonic sei- zures are often associated with some tonic contractions of the chest and some cyano- sis. Observers often believe that the child will swallow her tongue, die, or suffer brain damage because of the lack of oxygen. None of these statements are true, but the medical system must explain that truth to the panic-stricken parents at the time the child is first seen. The parents were just as frightened as if it had been a seizure since they believed that it was a seizure and need just as much reassurance. The appropriate work-up should be done if necessary but the parents can be reas- sured, regardless of the nature of the event. They will be relieved that the episode was a seizure or anything else serious. Tell them that if it occurs again it will be critical for them to carefully observe the circumstances and the order in which things happen. Assure them that if a similar episode recurs their child will recover just as he has after this episode and with a better history you can rethink the diagnosis. The most 60 Freeman important role of the physician managing a child and the family after a first seizure is to provide appropriate information about what seizures are and what they are not. In particular, the following should be emphasized: Reassurance about swallowing the tongue, suffering hypoxic damage to the brain and dying should be given. Limitations on the activities of daily living, riding bikes, swimming are unreasonable even after a first seizure.

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Near the end of each interview with individuals with difficulty walking buy 20 mg levitra soft overnight delivery, I asked whether they viewed themselves as “disabled buy levitra soft 20 mg on line. They spoke the language that historically has defined our collective national ethos: remaining independent purchase levitra soft 20 mg otc, doing things for themselves order levitra soft 20 mg otc, taking respon- sibility for their lives discount levitra soft 20mg with visa, not being a burden on others,“standing on their own two feet. Margaret Freemont in her early seventies was an emeritus university professor. Other people struggle with straight hair and ugly dispositions, bad teeth, no education, and bad husbands. People of privilege (certainly Nancy Mairs and myself) may too easily dis- miss the linguistic debate. Looking especially to the third world, Charlton (1998, 82) compellingly describes persistent poverty, discrimination, and disenfranchisement among many people with disabling conditions, noting that “disability identification takes place as people begin to recognize their oppression. The catch-22 for those who reject the disability label is that they might need it to live. Sally Ann Jones is a widow and no longer works; she gets So- cial Security disability insurance (SSDI) and Medicare through SSDI. Many interviewees who deny they are disabled nonetheless seek handicapped placards for their cars and park in handicapped parking spaces, use paratran- sit systems, or get disability income support. Each person has allowed an ex- ternal party—physicians and administrative authorities—to label them as “disabled” so they can receive a specific accommodation or benefit. People must acknowledge “disability” to obtain services that allow them to live the “more normal” lives they want—to not be disabled. One of my earliest interviewees was an older man who used a scooter-wheelchair following extensive surgery for cancer in his leg muscles. When I asked him to describe his trouble walking, he replied that he had no trouble: he didn’t walk. He used the RIDE, our local public wheelchair van service, almost daily to go wherever he wished, in- cluding adult education, the symphony, and theater. He said he was begin- ning to feel disabled because he couldn’t pull up his pants. For many decades, people have tried to place the concept of “disability” within broader ideas about how health and physical functioning interact with full participation in societies (Pope and Tarlov 1991; Brandt and Pope 1997; Altman 2001; Williams 2001; World Health Organization 1980, 2001). Disabled people could not hunt, tend fields, or labor to support themselves, and communities decided they merited alms or other assistance. But societies struggled to distinguish deserving from undeserving, fakers from truly disabled people. In the mid 1800s new medical discoveries, insights about Mobility Limits / 7 disease, and inventions like the stethoscope seemingly provided the solu- tion: “scientific medicine offered the promise of new diagnostic methods that could distinguish between genuine disability (or inability to work) and feigned disability. This ascendancy of “objective medical science” produced one way of thinking about disability, often called the “medical model. Management of the dis- ability is aimed at cure or the individual’s adjustment and behaviour change. Medical care is viewed as the main issue” (World Health Organi- zation 2001, 20). Today’s health-care delivery and payment systems, such as Medicare, reflect this medical model, largely focusing on treating ail- ments and making people “better,” returning them to “normal. Embedded within this medical model, however, are two assumptions: that disability is something individual people should strive, largely alone, to overcome; and that clinical professionals know what is best for their in- dividual patients. Leaders in the disability rights movement observed almost forty years ago that “prob- lems lie not within the persons with disabilities but in the environment that fails to accommodate persons with disabilities and in the negative at- titude of people without disabilities” (Olkin 1999, 26). As the wheelchair user Michael Oliver observed, disability is “imposed on top of our impair- ments by the way we are unnecessarily isolated and excluded from full participation in society” (1996, 22). These arguments coalesced into the “social” or “minority” model of disability. It sees disability not as “an at- tribute of an individual, but rather a complex collection of conditions, many of which are created by the social environment.... The issue is therefore an attitudinal or ideological one requiring social change, which at the political level becomes a question of human rights” (World Health Or- ganization 2001, 20). These positions girded and motivated critical strides toward disability civil rights in the United States over the last thirty years. Although this model lays responsibility across society, it offers an important message to individuals, articulated by the late American sociologist Irving Zola (1982), a leading thinker of the disability rights movement: We with handicaps and chronic disabilities must see to our own in- terests. We must free ourselves from the “physicality” of our condi- tions and the dominance of our life by the medical world. In particu- 8 obility Limits lar, I refer to the number of times we think of ourselves and are thought of by others in terms of our specific chronic conditions.

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