By S. Peratur. Pacific University.

No one was sure what these regimens were supposed to do but they seemed to help in some cases purchase keftab 250 mg visa antibiotic 272. It was said that the exercise strengthened the abdominal and back muscles and that this somehow supported the spine and prevented pain buy keftab 750mg with visa virus infection. The experience of treating these patients was frustrating and depressing; one could never predict the outcome. Further, it was troubling to realize that the pattern of pain and physical examination findings often did not correlate with the presumed reason for the pain. For example, pain might be attributed to degenerative arthritic changes at the lower end of the spine but the patient might have pain in places that had nothing to do with the bones in that area. Or someone might have a lumbar disc that was herniated to the left and have pain in the right leg. Along with doubt about the accuracy of conventional diagnoses there came the realization that the primary tissue involved was muscle, specifically the muscles of the neck, shoulders, back and buttocks. But even more important was the observation that 88 percent of the people seen had histories of such things as tension or migraine headache, heartburn, hiatus hernia, stomach ulcer, colitis, spastic colon, irritable bowel syndrome, hay fever, asthma, eczema and a variety of other disorders, all of which were strongly suspected of being related to tension. It seemed logical to conclude that their painful muscle condition might also be induced by tension. In fact, it was then possible to predict with some accuracy which patients would do well and which would probably fail. That was the beginning of the diagnostic and therapeutic program described in this book. TMS is a new diagnosis and, therefore, must be treated in a manner appropriate to the diagnosis. When medicine learned that bacteria were the cause of many infections, it looked for ways to deal with germs— hence the antibiotics. If emotional factors are responsible for someone’s back pain one must look for a proper therapeutic technique. Instead experience has shown that the only successful and permanent way to treat the problem is by teaching patients to understand what they have. To the uninitiated that may not make much sense but it should become clear as one reads on. Unfortunately, what has come to be known as holistic medicine is a jumble of science, pseudoscience and folklore. Anything which is outside mainstream medicine may be accepted as holistic, but more accurately described, the predominant idea is that one must treat the “whole person,” a wise concept that is generally neglected by contemporary medicine. But that should not give license to identify anything as holistic that defies medical convention. Perhaps holistic should be defined as that which includes consideration of both the emotional and structural aspects of health and illness. On the contrary, it becomes increasingly important to require proof and replication of results when one adds the very difficult emotional dimension to the medical equation. I hope it is an example of good medicine—accurate diagnosis and effective treatment, and good science—conclusions based on observation, verified by experience. Though the cause of TMS is tension, the diagnosis is made on physical and not psychological grounds, in the tradition of clinical medicine. All physicians should be practitioners of “holistic medicine” in the sense that they recognize the interaction between mind and Introduction xi body. To leave the emotional dimension out of the study of health and illness is poor medicine and poor science. There is an important point to be emphasized: Though TMS is induced by emotional phenomena, it is a physical disorder. It must be diagnosed by a physician, someone who is capable of recognizing both the physical and psychological dimensions of the condition. Psychologists may suspect that patients’ symptoms are emotionally induced but, not trained in physical diagnosis, cannot say with certainty that they have TMS. Since very few physicians are trained to recognize a disorder whose roots are psychological, TMS falls between the cracks, as it were, and patients go undiagnosed. It is particularly important that the diagnosis be made by a physician to avoid the pejorative conclusion that the pain is “all in the head. I have written a number of medical papers and chapters for textbooks on the subject but they have reached a limited medical audience, primarily physicians working in the field of physical medicine and rehabilitation. In recent years it has become impossible to have medical papers on TMS accepted for publication, undoubtedly because these concepts fly in the face of contemporary medical dogma.

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The patient should be asked screening ques- beliefs about technologic interventions to prolong life buy keftab 500 mg cheap antibiotic cephalexin, tions about independence and self-care—ability to get 82 keftab 750mg line antibiotic resistance is caused by,83 what defines life quality for the patient as an individual, out of bed, dress, shop, and cook. Any reported or and with what decrements the patient would still think observed difficulty should provoke more elaborate ques- life were worth living. Documenting discussions, execut- tions concerning dependence in activities of daily liv- ing a living will, and designating a proxy decision maker ing (ADLs: mobility, bathing, transferring, toileting, 84 and durable power of attorney for health care are part continence, dressing, hygiene, and feeding ) and in of this process of helping the patient have a voice in instrumental activities of daily living (IADLs: shopping, decisions that may need to be made when the patient, cooking, cleaning, managing money, telephoning, laundry, 86 28 by reason of illness, cannot participate. Questions should also be asked about vision, hearing, continence, and depression; deficits should be followed up. A brief screening instrument 85 Physical Examination for common impairments, administered by trained non- medical personnel, was found to be inexpensive and General appearance of the older patient should include clinically useful (i. Beyond age 60, these signs do not identify neglect, or poverty; hygiene and grooming) deserve increased risk. Merely observing how long it takes for the Visual acuity and hearing screening are necessary, patient to get ready for examination and the extent and given the high prevalence of impaired vision and audi- nature of help that may be required remains a useful and tory acuity among older persons. Hypothermia is visual impairment was found predictive of mortality in 10 more common, and reliable low-reading thermometers years, whereas combined impairment confers the highest are essential, especially for emergency room and winter- risk of 10-year functional dependence. Blood pressure should be taken in the supine situations, a pocket Snellen chart, held 14 in. Orthostatic hypotension, defined as pered voice is as sensitive as an audioscope for detection either 20 mmHg drop in systolic pressure or any drop of hearing loss,95,96 but the latter is, to date, the best objec- accompanied by typical symptoms, occurs in 11% to 28% tive measurement of hearing and more accurate at fol- of individuals older than 65 years. Inspecting the ear canals and blood loss, postural hypotension is a fairly specific but drums using an otoscope is especially necessary if hear- poorly sensitive sign of hypovolemia. Al- widely recommended in the past, is not reliable in older though on the decline, oral cancers are most common people. Specific assessment of general or local- than for ipsilateral stroke, and may cease unpredictably. Fat diminished, making breast tissue and the Skin undergoes many changes with age, including tumors that arise from it more easily palpable. Wrinkl- screening mammograms annually or every other year ing is more powerfully predicted by sun exposure and should be continued lifelong or until a decision is reached cigarette smoking than by age. Most proliferative le- that a discovered cancer would not be treated100; age- sions, benign and malignant, are related to sun ex- specific breast cancer incidence increases at least until posure; accordingly, basal and squamous cell cancers and age 85, and no evidence indicates that treatment is not melanomas should be most aggressively hunted on effective in older women. Because of skin aging, turgor is not a for breast cancer screening suggest yearly mammography reliable sign of hydration status. All skin should be until age 69, but there has been much discussion about examined, exposed to sun or not, for evidence of estab- revising the age to 74, 79, or removing an upper age limit lished or incipient (nonblanching redness) pressure entirely. Ecchymoses should also be noted, whether due to part of the Medicare benefit, and age cutoffs or stopping purpura of thin old skin or trauma; the possibility of screening on the basis of age alone is controversial (see abuse should be considered. Routine screening mammo- Head and neck examination begins with careful obser- grams should be continued with the understanding vation of sun-exposed areas for premalignant and malig- that the patient and/or family are aware that an abnor- nant lesions (as above). Palpation of temporal arteries for mal result will provoke more aggressive evaluation. Musculoskeletal examination, often a source of abun- Cardiac examination has several special features in dant complaints and pathology in older adults, begins aged patients. In the absence of complaints or common at baseline without symptoms or ominous prog- loss of function, brief tests of function are adequate to nosis. For upper extremity, 4 free of cardiac disease, S3 is associated with congestive "Touch the back of your head with your hands" and "Pick heart failure. The ubiquitous systolic ejection murmur is up the spoon" are sensitive and specific. A loud murmur from a chair, walk 3 m, turn, walk back, and sit down); (>2/6), diminution of the aortic component of S2, nar- requiring that each foot be off the floor in the "up and rowed pulse pressure, and dampening of the carotid go" yields a test that is a better predictor of functional upstroke suggest aortic stenosis, but each may be absent deficits than standard detailed neuromuscular examina- and be falsely reassuring. Although for decades aortic sclerosis was con- or itching or dyspareunia, is remarkably easy and grati- sidered benign, it has recently been associated with fying to treat. Topical (often difficult for the elderly increased risk for myocardial infarction, congestive woman with arthritis to manage) or oral conjugated heart failure, stroke, and death from cardiovascular estrogen may often be discontinued after a few weeks causes, even without evidence of significant outflow without return of symptoms.

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The panel The interview panels differ in style and substance between schools but typically consist of three or four members of staff and often a student purchase 125mg keftab virus mac. The 53 LEARNING MEDICINE panel is a mixture of basic scientists order keftab 750mg overnight delivery antimicrobial jacket, hospital consultants, and general practitioners, one of whom, often the dean or admissions tutor, will take the chair. Members of panels attend in an individual capacity and not as representatives of particular specialties. They know that medicine offers a wide range of career opportunities, that most doctors will end up looking after patients but not all do, that more will work outside hospitals than in, and that both the training and the job itself are demanding physically and emotionally. They also know that whatever their final occupation doctors need to make decisions, deal with uncertainty, and communicate effectively and compassionately with patients and colleagues alike as well as maintaining moderately exacting academic standards. The aim is not to pick men and women for specific tasks but to train wise, bright, humane, rounded individuals who will find their niche somewhere in medicine. The format may be formal, with the interview conducted in traditional fashion across a large table, or more informal, sitting in comfortable chairs around a coffee table by the fireside. The tenor of the interview, however, depends much more on the style of questioning; no matter how soft the armchairs are, they can still feel decidedly uncomfortable if you are made to feel like you are being grilled and about to be eaten for breakfast. Dress and demeanour Although the interview is a chance to be yourself and sell yourself, there are certain codes of conduct that even the most individual or eccentric candidate should be encouraged to heed. Dress smartly and comfortably and make an effort to look as presentable as you would expect from a mature professional. If your usual style of clothing is rather off beat, then perhaps for once it may be wise to let your tongue make any statements about your individuality rather than your all in one leather number and preference for nose piercing. Nothing is more of a turn off to interviewers than someone who is full of himself (or herself! On the other hand an obviously talented and caring student whose modesty and nerves get the better of him and who fails to give the panel any reasons at all to give him an offer is almost as frustrating. When asked to blow your own trumpet make it sound like a melodious fugue not a ship’s fog horn. Many schools will be able to organise mock interviews, which can be useful, but often the more specific points relating to entering medical school can be best thought through by enlisting the help of your local family doctor or a family friend who is a doctor or by talking to anyone experienced in interviewing or being interviewed in any context or by asking the advice of people who have themselves recently been through it when you visit the medical schools on open days or tours. You should be able to show you have a realistic insight into the life of a doctor, and this is often best achieved by relating personal experience of spending some time with a doctor in hospital or general practice or, for example, by voluntary work in an old people’s home or with children with special needs. Some panels put great store by your showing them how much you can achieve when you put your mind to it and will want to discuss your expedition to Nepal, your work on the school magazine, your musical or sporting successes. Remember to keep a copy of your UCAS form personal statement to read before you go into your interview. It is very often used as a source for questions and it can be embarrassing if you appear not to remember what you wrote. Even more importantly, do not invent interests or experience, as you may get caught out. One candidate at interview recently struggled through his interview after he was asked about the voluntary work at a local nursing home which he put on his form and replied: "I haven’t actually got round to doing it yet, but I’d like to. It is often sensible to have kept in touch with current affairs and developments in research. This is particularly relevant if the medical school has a strong interest in a research topic which has a high media profile. By reading a good quality daily newspaper you will greatly assist your ability to provide informed comment on issues of the moment. One candidate at interview cited the strong research background as a reason for applying to that school, and when asked to discuss which research at the school impressed him he replied: "Fleming’s discovery of penicillin". He knew he had not done himself any favours when the dean replied: "Could you not perhaps think of anything a little more recent than 1928? Specific questions on subjects such as abortion, religion, or party politics are discouraged, but if they are likely to cause personal professional dilemmas it is reasonable and sensible to have thought about them and to be able to discuss how you would approach resolving such issues. Candidates with special circumstances, especially mature students, should be fully prepared for the interview panel to concentrate on particularly relevant factors such as whether they can afford to support themselves during the course, rigorous testing of their motivation, and questioning of the reasons behind their decision to enter the medical profession.

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