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Chesterton – First in line to British throne British writer I believe it is most certainly possible to design Psychoanalysis is confession without absolution purchase 50 mg sildigra with visa erectile dysfunction ed treatment. The spirit needs healing as well It seems a pity that psychology should have as the body purchase sildigra 120 mg otc treatment erectile dysfunction faqs. Attributed Attributed Is the whole of the health care system—and the Sir Watson Cheyne – confidence of the public in it—not undermined by Surgeon 50 mg sildigra free shipping what is erectile dysfunction wiki answers, Professor of Surgery sildigra 120 mg generic erectile dysfunction type of doctor, King’s College, London, the publicity given to what goes wrong rather scientist and assistant to Joseph Lister than the tiny miracles wrought day in day out by an expert, kind and dedicated staff? It Speech to newspaper editors and proprietors in Fleet Street, is not a thing which should be meddled with by March () people who do not know it as intimately as it is possible to know it. Guy de Chauliac – Quoted with reference to a quack bone setter in Harley Street p. Michael Joseph, London French surgeon () The conditions necessary for the surgeon are four: first, he should be learned: second, he should be Chinese proverbs expert: third, he must be ingenious, and fourth, he should be able to adapt himself. Before thirty, men seek disease; after thirty, Ars Chururgic Introduction diseases seek men. A blind man works on wood the same way as a Before you tell the ‘truth’ to the patient, be sure surgeon on the body, when he is ignorant of you know the ‘truth’ and that the patient wants to anatomy. He that takes medicine and neglects to diet himself Anton Chekhov – wastes the skill of the physician. Russian dramatist and doctor However strong a mother may be, she becomes When a lot of remedies are suggested for a disease, afraid when she is pregnant for the third time. Ivanov It is easy to get a thousand prescriptions, but hard I realise I have two professions, not one. When I grow weary of one, I pass the night with Medicine cures the man who is fated not to die. Letter, October () No man is a good doctor who has never been sick himself. Chen Jen Only the healing art enables one to make a name Chinese sage for himself and at the same time give benefit to When you treat a disease, first treat the mind. The appearance of a disease is swift as an arrow; Earl of Chesterfield – its disappearance slow, like a thread. Advice is seldom welcome; and those that want it The patient has two sleeves, one containing a the most always like it the least. Continued · Chinese proverbs continued Charles Churchill – The unlucky doctor treats the head of a disease; English satirical poet the lucky doctor its tail. Most of those evils we poor mortals know To be uncertain is to be uncomfortable, but to be From doctors and imagination flow. Dreams, Children of night, of indigestion bred, Which, Reason clouded, seize and turn the head. Sir Winston Churchill – Attributed British statesman I must point out that my rule of life prescribes as an absolutely sacred rite smoking cigars and also W. Parturition is a physiological process—the same in Uttered during a lunch with the Arab leader, Ibn Saud the countess and in the cow. There is no finer investment for any community Quoted in Familiar Medical Quotations Maurice B. Little, Brown and Company, Boston () Radio broadcast, March () I can think of no better step to signalize the A. Christie – inauguration of the National Health Service than British infectious disease physician that a person who so obviously needs psychiatric attention should be among the first of its patients. Man is a creature composed of countless millions Speech, July () about Labour’s Health Secretary of cells: a microbe is composed of only one, yet Aneurin Bevan throughout the ages the two have been in ceaseless conflict. Science bestowed immense new powers on man, Infectious Disease, Epidemiology and Clinical Practice p. The and, at the same time, created conditions which Epidemiologist and the Clinician (th edn) () were largely beyond his comprehension and still more beyond his control. The history of epidemics is the history of wars Speech at the Massachusetts Institute of Technology, and wanderings, of famine and drought and of March () man’s exposure to inhospitable surroundings. When man has travelled rough, microorganisms Scientists should be on tap, but not on top. Falconer) Maxims (–) No one is so old as to think he cannot live one more year. Chinese sage Pro Caelio To avoid sickness eat less; to prolong life worry One should eat to live, not live to eat. The medical errors of one century constitute the Annals of Ireland (relating the effects of the Black Death in popular faith of the next. I would rather that any white rabbit on earth Attributed should have Asiatic cholera twice than that I Symptoms which cannot be readily marshalled should have it just once. Bartholomew’s Hospital, London Forrester Cockburn – The young gastroenterologist of today is only Professor Child Health, Glasgow, Scotland happy if he can learn another endoscopic The origins of physical and mental health and technique, the excitement of the ’s has been disease lie predominantly in the early development replaced by the decade of the Peeping Tom. Lancet : () Preface to Children’s Medicine and Surgery () Sir Stanley Clayton ? British obstetrician Jean Baptiste Coffinhal-Dubail Until the end of the last century, and indeed, until ? Comment at trial of Antoine Lavoisier, Paris () Obstetrics by Ten Teachers (th edn, p. Henry, Lord Cohen of Birkenhead Attributed – Men are not going to embrace eugenics. They are British physician going to embrace the first likely, trim-figured girl with limpid eyes and flashing teeth who comes All diagnoses are provisional formulae for action. Annals of the Royal College of Surgeons of England : Attributed () . Charles Caleb Colton – Miscellanies, Aesthetic and Literary English clergyman, sportsman, author, and suicide Oh sleep! The poorest man would not part with health for Table Talk July () money, but the richest would gladly part with all their money for health. Alex Comfort – Epilogue to The Plague of the Spanish Lady (influenza English physician and sexologist epidemic October –January ) The idea of the human responsibility of the doctor has been present since medicine was John Churton Collins – indistinguishable from magic. Collins) Positivism To understand a science it is necessary to know its Mortimer Collins – history. British writer Positive Philosophy (–) A man is as old as he’s feeling, A woman as old as she looks. Arthur Conan Doyle – The Unknown Quantity British crime novelist The true way to render age vigorous is to prolong Education never ends, Watson. Thomas and George Underwood, London () Cyril Connolly – (Description of the first ligation of the aorta in for left British journalist and writer femoral aneurysm) The one way to get thin is to re-establish a purpose Sir (Vincent) Zachary Cope in life. The Unquiet Grave Pt I – See Zeta Obesity is a mental state, a disease brought on by boredom and disappointment.
Pulmonary exam tries to elicit the rales and rhonchi frequently associated with congestive heart failure purchase sildigra 120mg overnight delivery impotence after robotic prostatectomy. Abdominal and peripheral exams are intended to find signs related to right-sided heart failure generic sildigra 100 mg without prescription erectile dysfunction treatment in lucknow, including hepatosplenomegaly and peripheral edema discount sildigra 50mg without a prescription erectile dysfunction age 27. Peripheral pulses are evaluated order sildigra 120 mg with amex erectile dysfunction doctor london, and the presence or absence of varicose veins should be noted in case bypass surgery is required. The presence or absence of a gallop rhythm indicative of heart failure is listened for. The typical aortic stenosis murmur is heard loudest over the second intercostal space to the right of the sternum and may radiate to the neck. It usually is a crescendo/ decrescendo murmur that may range from mid- to holosystolic. An aortic insufficiency murmur usually is loudest in the fourth intercostal space to the left of the sternum, and is a diastolic decrescendo murmur that can be heard best with the patient leaning forward, and may be associated with a widened pulse pressure. Mitral stenosis is heard loudest at the apex of the heart, which usually is not displaced, since left ventricular enlargement is unusual. A mitral insufficiency murmur is holosystolic, blowing, loudest at the apex, and may radiate to the axilla. Chest X-Ray Frequently, the history and physical give an accurate picture by which the diagnosis can be made. The chest x-ray can be helpful for con- firming signs of cardiomegaly, chamber enlargement, pulmonary congestion, etc. An associated aortic dilatation of an ascending aortic aneurysm associated with aortic insufficiency may be present. Conduction defects, especially in the presence of active endocarditis, should be sought. Other changes are suggestive of associated coronary artery disease that also must be addressed. Echocardiogram The easiest and currently most accurate noninvasive test used in evaluating valvular heart disease is the echocardiogram, more specif- ically the transesophageal echocardiogram. These studies permit a simple screening for the presence and severity of a valvular lesion. At the same time, the presence of chamber enlargement or dysfunction can be determined. A simple method thus exists to permit the ongoing eval- uation of patients not yet deemed candidates for surgery. The presence or absence of calcification that might increase the complexity of surgery can be identified, and information can be provided on the suitability of a patient for mitral valve repair. If these studies indicate the need, cardiac catheterization usually is recommended. If surgery is not needed at the time of initial evaluation, echocardiogram provides a simple method for ongoing evaluation. Cardiac Catheterization Both left and right heart catheterizations are performed on most patients being evaluated for valve surgery. Right heart catheteriza- tion usually employs a Swan-Ganz catheter inserted via a large vein into the right heart. Measurements of right-sided chamber pressures, the pulmonary artery pressure, and the pulmonary capillary wedge pressure (which reflects the left atrial pressure) are made. In a left heart catheterization, a catheter is passed from the femoral or brachial artery back though the aorta to the heart. It is used to measure pressures in the aortic root and left ven- tricular chamber. The gradient across the mitral valve is the differ- ence between simultaneous measurements of pulmonary capillary wedge pressure (the equivalent of left atrial pressure) and left ventric- 274 A. The valve areas then can be calcu- lated using the Gorlin formula that relates the area of the valve to the pressure gradient across the valve and the cardiac output. Coro- nary angiography is performed to look for any associated coronary disease that could be repaired simultaneously during surgery. In some younger patients and in some emergency situations, the information provided by the echocardiogram may be sufficient and heart catheter- ization may not be required. Therapeutic Intervention Indication for Surgery Decisions regarding the management of patients with valvular heart disease are based on the recognized progression of the various lesions and the risk versus benefit of surgical intervention. Until the ideal replacement valve is developed, the inherent risks associated with prosthetic valves (limited durability, need for anticoagulation, propensity for infection, sound) must be considered along with the risk of the operation itself. One pathologic situation (the deformed valve) is being substituted with another (the prosthetic valve when needed), although with a different array of potential problems. Associated coro- nary artery disease, especially in the presence of mitral regurgitation, significantly increases operative mortality. Thus, the decision is one of the benefits of preventing further deterioration in ventricular function, death, or other complications related to the valve disease versus the risk of surgery, the patient’s likelihood to regain or main- tain an acceptable lifestyle, and the risks inherent in the new valve substituted. Patients with new-onset symptoms are treated medically to relieve symptoms of congestive heart failure or angina. Congestive heart failure is treated with diuretics, digoxin, and afterload reduction when it can be tolerated. Great care must be taken in patients with aortic stenosis to avoid overdiureseis or too much preload reduction (with nitroglycerine and diuretics), which can result in inadequate filling of the left ventricle and subsequent syncope or low output. Heart rate must be controlled with beta-blockers digoxin or calcium channel blockers to permit adequate chamber filling, espe- cially when stenotic lesions are present. Anticoagulants are needed for patients in atrial fibrillation to prevent systemic embolization. There is some evidence that the use of the calcium channel blocker Procardia in asymptomatic patients with aortic insufficiency may delay their need for surgery. Once diagnostic studies have been completed, recommendations for chronic medical therapy or surgery are made. Heart Murmurs: Acquired Heart Disease 275 must be made on an individual basis and must involve an informed consent from the patient and family. Medical therapy is used for those patients when it is believed the surgical risk is too high or their long-term benefit is not sufficient for surgery. Others who are not yet ready for surgery receive medical therapy but are followed closely until indications for surgery become manifest. As noted, the surgical management of valvular heart disease is dependent on the risk-benefit ratio for the patient. Unfortunately, this is not always so clear when the risk of the operation is high and the benefit to an individual patient not clear. However, generalized indi- cations for surgery have evolved based on short- and long-term outcome studies. Detailed diagnostic and therapeutic guidelines are well summarized in “Consensus Statement on Management of Patients with Valvular Heart Disease,” developed by a combined task force of the American Heart Association and the American College of Cardiology. Any patient with symptomatic aortic stenosis should undergo valve replacement unless there are significant contraindica- tions or the patient’s life expectancy is otherwise severely limited. Even those patients with significant organ dysfunction secondary to the low output state may be considered.
Anions characteristics/Electrophoresis/1 migrate toward the anode (positive electrode) buy sildigra 100 mg lowest price erectile dysfunction doctors in queens ny. B Electrophoresis is the migration of charged molecules anode will decrease by increasing the: in an electric field buy sildigra 25mg with amex vacuum pump for erectile dysfunction in pakistan. Voltage buffer move with the proteins sildigra 100 mg mastercard impotence diagnosis code, reducing their Chemistry/Apply principles of basic laboratory electromagnetic attraction for the anode best sildigra 50 mg erectile dysfunction treatment himalaya. Cathodal sample application the anode and may cause some γ–globulins to be Chemistry/Apply principles of basic laboratory displaced toward the cathode. Which of the following conditions will prevent presence of a salt bridge that allows current to flow any migration of proteins across an electrophoretic via transport of ions to the electrodes across the support medium such as agarose? Loss of contact between a buffer chamber and acetate, heat causes evaporation of solvent from the the medium buffer. Power = E (voltage) × I (current) × t (time); since Chemistry/Apply principles of basic laboratory E = I × R (resistance), heat is proportional to the procedures/Electrophoresis/3 square of current (P = I2 × R × t). IgG Because albumin is fastest, it has the greatest net Chemistry/Apply knowledge of fundamental biological negative charge and lowest pI (about 4. Which of the following proteins migrates in the Answers to Questions 16–20 β region at pH 8. High-resolution procedures detect monoclonal a cooling device to resolve 12 or more bands. Malignancy Chemistry/Correlate clinical and laboratory data/ and rheumatoid arthritis produce polyclonal Electrophoresis/2 gammopathies classified as chronic inflammatory or delayed response patterns. Which support medium can be used to determine produces a zone of restricted mobility usually in the molecular weight of a protein? Agarose gel is a nonionic detergent that binds to proteins, Chemistry/Apply principles of special procedures/ neutralizing their charge. Which of the following stains is used for The smaller proteins become trapped in the pores lipoprotein electrophoresis? Coomassie Brilliant Blue is more sensitive than Chemistry/Select reagents/Media/Blood products/ Ponceau S or Amido Black, and all three stains have Electrophoresis/1 slightly greater affinity for albumin than globulins. What is the clinical utility of testing for serum electrophoresis results suggests an acute prealbumin? Levels correlate with glomerular injury in patients with diabetes mellitus Chemistry/Correlate clinical and laboratory data/ Chemistry/Apply knowledge of fundamental biological Electrophoresis/2 characteristics/Nutrition markers/1 22. Which of the following conditions is usually associated with an acute inflammatory pattern? Hepatitis include α1-antitrypsin, α1-acid glycoprotein, α1-antichymotrypsin, and haptoglobin. This pattern results densitometric tracing most likely indicates: from production of acute phase proteins including A. A This pattern shows a marked decrease in the α1-globulin (slightly less than one-fifth of the expected peak area). Staining of the α1-globulin fraction is predominately determined by the α1-antitrypsin level. Patients with α1-antitrypsin deficiency often display elevations in the α2-globulin and γ-globulin fraction because the condition is associated with chronic emphysema and hepatic cirrhosis. C Prealbumin (also called transthyretin) is a small Chemistry/Evaluate laboratory data to recognize health protein with a half-life of only 2 days. Serum levels and disease states/Proteins and enzymes/2 fall rapidly in patients with deficient protein nutrition. As a result, prealbumin is used to detect malnutrition and to measure the patient’s response to dietary supplementation. The cutpoint used to identify nutritional deficiency in elderly patients is usually 11 mg/dL. Which serum protein should be measured in a Answers to Questions 25–29 patient suspected of having Wilson’s disease? Levels are low in almost all patients with Chemistry/Apply knowledge of fundamental biological Wilson’s disease, an autosomal recessive disorder characteristics/Proteins/2 caused by accumulation of copper in liver, brain, 26. Low ceruloplasmin may associated with septicemia has a haptoglobin occur in patients with nephrosis, malnutrition, level that is normal, although the plasma free and hepatobiliary disease. Therefore, the diagnosis hemoglobin is elevated and hemoglobinuria is of Wilson’s disease is made by demonstrating present. Which test would be more appropriate decreased plasma ceruloplasmin, increased urinary than haptoglobin to measure this patient’s copper, and the presence of Kayser–Fleischer rings hemolytic episode? Transferrin when intravascular hemolysis produces more than Chemistry/Apply knowledge to recognize inconsistent 3 grams of free plasma hemoglobin. However, laboratory results/Proteins/3 haptoglobin is an acute phase protein, and hepatic 27. Quantitative determination of Hgb A2 and Hgb F production and release are increased in response are best performed by: to acute infections. High-performance liquid chromatography is most likely the result of increased synthesis and B. A Hgb A2 and Hgb F are often quantitated to diagnose Chemistry/Apply principles of special procedures/ persons with thalassemia. Select the correct order of Hgb migration on increasing positive charge using a sodium phosphate agarose or cellulose acetate at pH 8. C Hgb A2 is the slowest of the normal Hgbs, Electrophoresis/2 and Hgb A is the fastest. Hgb E migrate to the same position as Hgb A2 on cellulose acetate or agarose at pH 8. Which Hgb is a β-δ chain hybrid and migrates to Answers to Questions 30–34 the same position as Hgb S at pH 8. HgbLepore is suspected when Hgb Electrophoresis/2 migrating in the “S” zone comprises less than 20% of 31. However, Hgb C and Hgb S bind to sulfated Chemistry/Apply principles of special procedures/ pectins in the agar gel, forming a complex that is Electrophoresis/2 negatively charged causing them to migrate toward 32. Hgb D migrates to the same Punjab results/Electrophoresis/2 position as Hgb S on agarose, but moves with Hgb A on citrate agar. Antisera are electrophoresed, then diffused identify monoclonal bands in serum or urine. Serum is electrophoresed; the separated sample in the same manner as for protein immunoglobulins diffuse against specific electrophoresis, except that six lanes are used for the antisera placed into troughs same sample. After the proteins are separated, a Chemistry/Apply knowledge of special procedures/ different monospecific antiserum is applied across Immunofixation/2 the surface of each lane. Invisible before the equivalence point is reached seen only in those lanes where the monoclonal B. Concave to the protein of greatest molecular immunoglobulins were recognized by the weight corresponding antiserum. Located in an area of antibody excess molecules of lower molecular weight move fastest through the gel, causing a visible precipitin arc when Chemistry/Apply knowledge of special procedures/ antigen and antibody approach equivalence. If the concentration of antisera is constant, the distance of the precipitin arc from the antigen well is proportional to antigen concentration. Te monoclonal band must be present in the concentration of each class of immunoglobulin γ region but does not distinguish monoclonal from B.
Typically generic 25 mg sildigra amex erectile dysfunction drugs lloyds, you live your life so much through the inner child that you lose the connection with your own adult voice generic 100 mg sildigra erectile dysfunction 40. You are not powerless and you can remind yourself that you can be present in any situation from an adult perspective purchase 100mg sildigra amex impotence juicing. To do this buy sildigra 100 mg line erectile dysfunction weight loss, initially, before you speak or act in response to an emotional situation, you can ask yourself the question, “Whose voice is this? Sometimes, it can be helpful to directly appeal to the adult within you by asking, “What would a wiser adult do in this situation? Knowing this, you can then make a more rational decision about how you’d like to proceed. Having identified your own core-wounding experiences as best you can, a more mature, adult response in an emotional situation may often be to simply do nothing. You can simply be present in the moment for what it is, uncluttered by what you believe it to be and the trappings of stories and reactions that are based on your childhood belief system. You also have the ability to move beyond your conditioned adult presence and tap into a place of wisdom, understanding and compassion. Listen for your own voice of wisdom, which is your intuitive, knowing, wise awareness. The voice of the adult is just a more conditioned, experienced reflex that has been progressively influenced by cultural, religious and secular values. It’s important to your health and well-being that your behaviors be directed by mature, integrated and wholesome practices, rather than by the inner child’s need to feel loved and accepted. To be truly adult means to be present in this world from a place that doesn’t need to satisfy childhood imperatives. Ideally, we would all strive to operate from a place of equanimity, fairness, justice, compassion and acceptance. However, we all have an internal, wise, knowing and intuitive self that we can tap into. When you become aware of your own mental chatter, simply ask, “What needs to be done now? Empathy in Everyday Life – Practice and Integration Let’s take everything that you’ve recently learned about inner-child dialogue, empathy and support and integrate it into a shorter version or summary dialogue, which you can use with your inner child during a stressful situation. To use a shortened version, you will need to have practiced the inner-child dialogue to the point where you have become quite familiar with your inner child and have a good idea of what your belief system is. In the beginning, you’ll need to practice a lot in order to become aware of what the child is experiencing and believes about particular types of events. You will discover that your child has its own unique core wounding and it uses the resulting coping strategies that it has developed (which you could also think of as defense mechanisms) over and over. As you progress with your inner-child dialogues, you’ll start to recognize these defense mechanisms and this will help you to shorten your inner-child dialogue so that you can use it to calm yourself during a stressful event. Initially, it may be difficult to use the inner-child dialogue in the heat of the moment. Remember, that you can always review an emotional event later, when there’s some time and privacy to have a dialogue. As you become more at ease and familiar with the process of dialoguing, you’ll be able to use a shortened version of the dialogue, or even just a part of it, in the moment that an emotional or stressful event is occurring. Empathy for the Inner Child• 205 Here are the components of the shortened/summary dialogue: 1. Actions on behalf of the child Awareness Initially, describe to yourself, as objectively as you can, the stressful event that has occurred or that’s currently unfolding. This is a good way to frame the rest of the conversation that you’ll have with your inner child. After describing the event as it initially presented itself, acknowledge the child’s reaction to it. Coming back to the example of when Larry bought the suit, Larry would have described the initial event and his inner child’s reaction by saying: My dear child, you bought a suit that you think is too expensive. Mika, in her situation, would have started with: My dear child, you didn’t bring the right file in and you’re worried that you’re not doing your job. Acknowledge the Feeling Step two is to acknowledge what emotion the inner child is feeling. Through your usual inner-child dialogue practice, you’ll have a much quicker sense of what the inner child’s core feeling is, in a given situation. If you don’t have a sense of what the child is feeling, you can directly question the child and ask how it’s feeling in the moment. This repetition is an acknowledgement that you know and understand what the child is feeling. If you were to discount, or minimize, the child’s feelings by saying, “You’re not sad. Everything’s good,” the child would again be in a place wherein a dismissal of its feelings renders it powerless and invisible. In Larry’s situation he would have said to his inner child: It sounds like you’re feeling scared and angry. Mika would have made the comment: It sounds like you’re feeling really nervous and worried. Stating the Belief System Your next step is to focus on the inner child’s belief system. Bringing the underlying belief into the open, instead of leaving it where it normally hides beneath your conscious awareness, will start to shed some light on what the motivating force is for your actions. State to your inner child what you think the child believes that is underlying its feelings and reactions. This isn’t just a belief about a current stressful situation but a general core belief that you’ve run into before in your inner-child dialogues. Stating the core belief from the belief system, that’s at work during a stress-reaction, will give you some additional clarity and a place to focus your attention in order to create change. For this third step Larry might have said something like: You believe that if you make any mistake you will not be loved. In this step, you provide an alternate view of the belief system for the inner child. Remember, that looking at something in a different way is the beginning of the reframing process. Through your inner-child dialogues, you have discovered the inner child’s belief system and from that discovery you are able to provide a more constructive way for the inner child to experience life. This reframing step is where you say something to the inner child that really challenges its beliefs. Mika could have said: My dear child, everyone is responsible for his or her own feelings. The child comes from a place of powerlessness and knowing that there are solutions to the perceived problem at hand is also reassuring. Additionally, if the child has said that it needs something in particular in order to feel reassured, the adult in you can specifically tailor some supportive statements to address those needs. Reframe or challenge the child’s beliefs by offering a different, more constructive way of looking at things.
