By O. Myxir. Le Moyne College.

I have a student who told me that whenever she concentrated on her navel in the morning and her husband moved his leg she could feel the energy in her own leg go into his buy 5 mg proscar free shipping man health 2014. In a short time she observed that his overall health had improved and he was no longer burdened with frequent headaches and colds discount proscar 5mg without prescription man health advisor. Another of my students, Richard Wu, rid himself of his allergies through Taoist Yoga. When his wife found herself simi- larly afflicted she asked to learn the method so that she too could find relief. It took her just one day to complete the micro orbit. Her husband came to me pleased by her accomplishment but puzzled, too, because it had taken him months to do the same thing. I ex- plained that that was not unusual and that their energies flowed in sympathy because they lived together and that being with a person who practices can lead to such results. Interviews Three Practi- tioners of Taoist Yoga by Lawrence Young, M. Young: I would like to do an extended study of people who meditate. It’s a venture that would call for a lot of follow up. Were you to take a drug for a month or so it would be fairly safe but were you to take it for 5 years it would not be. In the same way, the medical field is very eager to learn about people who meditate for a lifetime. That might include people who have problems, what the nature of those problems are, how they get problems and what they do to be rid of them. I’d like to know how you came to practice with Master Chia, whether there was any health problem that brought you into it or whether it was simply because you were interested in it. S: I hurt my back about 6 years ago and ever since then have a hard job sitting, let alone lying down. I couldn’t sleep through a whole night, my neck especially would hurt me. Ever since I came to practice with Master Chia, in fact, immediately upon trying this, the pain abated. As though to prove the point, about 2 or 3 weeks ago I became a little slipshod about my practice. There are formulae you have to do — exercises might be a better term — and I was pressed for time and began to find excuses. I cut down the number of repetitions that were called for in each of the meditations and sure enough, my neck began to hurt again and my back has begun to hurt gain, too. I don’t really know, it may be a purely circumstantial thing. There may be other factors involved in this case, but it would seem over the years that I tried various things and had no help. It is more than - 136 - Chapter XIII coincidence that when I tried Master Chia’s practice it did seem to help. I had the usual orthopedic treatments with hot soaks and analgesics and muscle relaxants, which had me walking around in a stupor. I went to a chiropractor with very transitory results, but with some arrest of pain. Then I went to an acupuncturist, who didn’t help at all. This practice seems to have done something, seriously. S: They said that there was severe muscle spasm — espe- cially of the upper back, involving the neck and the area that was subscapular.

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Chapter 1 Assessment and Clinical Decision-Making: An Overview linical decision-making is often fraught with uncertainties purchase 5 mg proscar with amex prostate cancer rates. However buy proscar 5mg with amex prostate numbers, expert diagnosticians are able to maintain a degree Cof suspicion throughout the assessment process, to consider a range of potential explanations, and then to generate and narrow their differential diagnosis, based on their previous experience, famil- iarity with the evidence related to various diagnoses, and under- standing of their individual patient. Through the process, they perform assessment techniques involved in both the history and physical examination in an effective and reliable manner and select appropriate diagnostic studies to support their assessment. Mary Jo Goolsby & Laurie Grubbs HISTORY Among the assessment techniques that are essential to valid diagno- sis is the performance of a “fact-finding” history. To obtain adequate history, providers must be well organized, attentive to the patient’s verbal and nonverbal language, and be able to accurately interpret the patient’s responses to questions. Rather than reading into the patient’s statements, they clarify any areas of uncertainty. The expert history, like the expert physical examination, is informed by the knowledge of a wide range of conditions, their physiologic basis, and their associated signs and symptoms. The ability to draw out descriptions of the patient’s symptoms and experiences is important, as only the patient can tell his or her story. To assist the patient in describing a complaint, a skillful inter- viewer knows how to ask salient questions to draw out necessary information without straying. A shotgun approach, with lack of focus, is not recommended and the provider should know, based on the chief complaint and any preceding information, what other ques- tions are essential to the history. It is important to determine the capacity of the symptom to bring the patient to the office, that is, the 2 Copyright © 2006 F. Assessment and Clinical Decision-Making: An Overview 3 significance of this symptom to the patient. This may uncover anxiety that the patient has about a certain symptom and why. It may also help to determine severity in a stoic patient who may underestimate or underreport symptoms. Throughout the history, interviewers recognize that patients may forget details, so prob- ing questions may become necessary. Moreover, patients sometimes have trouble finding the precise words to describe their complaint. However, good descriptors are necessary to isolate the cause, source, and location of symptoms. Often, the patient must be encouraged to use common language and terminology, to tie a symptom to something common. For instance, encourage the patient to describe the problem to you just as he or she would describe it to a relative or neighbor. The history should include specific components, to ensure that the problem is compre- hensively evaluated. These components are summarized in Table 1-1, and the specific ques- tions to include in each section are described in detail in subsequent chapters. PHYSICAL EXAMINATION The expert diagnostician must also be able to perform a physical assessment accurately. This requires extensive practice with all components of the physical examination and keen Table 1-1. Important to consider using the patient’s terminology. History of Present Illness To provide a thorough description of the chief complaint and current problem. P: precipitating and To identify factors that make symptom worse and/or better; any previ- palliative factors ous self-treatment or prescribed treatment, and response. Q: quality and quantity To identify patient’s rating of symptom (e. R: region and radiation To identify the exact location of the symptom and any area of radiation. S: severity and associated To identify the symptom’s severity (e. T: timing and temporal To identify when complaint was first noticed; how it has changed/pro- descriptions gressed since onset (e. Past Medical History To identify past diagnoses, surgeries, hospitalizations, injuries, allergies, immunizations, current medications.

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Medical therapy is less effective than tumor resection but can be used in patients who are not candidates for surgery proven proscar 5 mg prostate cancer 3 of 12. The most effective medication for controlling symptomatic hypoglycemia is diazoxide proscar 5mg with mastercard mens health 30-30 workout, which lowers insulin production. Other medica- tions for insulinomas include verapamil, phenytoin, and octreotide. A 31-year-old woman presents to the emergency department complaining of episodes of dizziness, light- headedness, palpitations, sweats, anxiety, and confusion. On the morning of admission, she reports that she almost passed out. Her husband, who is a diabetic patient who requires insulin, checked her blood sugar level and noted it to be low. Her symptoms resolved after drinking some orange juice. She is admit- ted to the hospital for a prolonged fast. After 18 hours, she becomes symptomatic, and her blood is drawn. The serum glucose concentration is 48 mg/dl, the serum insulin level is high, and test results are negative for insulin antibodies. The C-peptide level is low, and tests for sulfonylurea and meglitinides are negative. Which of the following is the most likely diagnosis for this patient? Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) D. Insulin autoimmune hypoglycemia Key Concept/Objective: To be able to recognize the patient with factitial hypoglycemia Factitial hypoglycemia is more common in women and occurs most often in the third or fourth decade of life. Many of these patients work in health-related occupations. Factitial hypoglycemia results from the use of insulin or drugs that stimulate insulin secretion, such as sulfonylureas or meglitinides. The possibility of factitial hypoglycemia should be con- sidered in every patient undergoing evaluation for a hypoglycemic disorder, especially when the hypoglycemia has a chaotic occurrence—that is, when it has no relation to meals 3 ENDOCRINOLOGY 15 or fasting. The diagnosis of factitial hypoglycemia can usually be established by measur- ing serum insulin, sulfonylurea, and C-peptide levels when the patient is hypoglycemic. In a patient whose hypoglycemia results from covert use of a hypoglycemic agent, the agent will be present in the blood. In insulin-mediated factitial hypoglycemia, the serum insulin level is high and the C-peptide level is suppressed, usually close to the lower limit of detec- tion, as seen in this patient. A 38-year-old man is brought to the emergency department after a generalized seizure. The complete blood count and results of a blood chemistry 7 panel are normal, with the exception of a low glucose level. A head CT is negative, and a lumbar puncture reveals no evidence of infection. After the patient is stabilized and able to give a history, he tells you that he has been experiencing episodes of dizziness, confusion, headache, blurred vision, and weakness for the past month. The episodes always occur about 2 hours after he eats. He has no other significant medical his- tory and takes no medications. Which of the following is the probable diagnosis for this patient? Insulin autoimmune hypoglycemia Key Concept/Objective: To be able to distinguish NIPHS from insulinoma NIPHS is a recently described entity. Like insulinoma, it affects patients across a broad age range (16 to 78 years) and causes severe neurohypoglycemia, with loss of consciousness and, in some cases, generalized seizures. Unlike insulinoma, it occurs predominantly in males (70%). Histologic analysis of pancreatic tissue from patients with NIPHS shows cells budding off ducts, seen best by chromogranin A immunohistochemical staining. No gross or microscopic tumor has been identified in any patient with NIPHS.

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