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11PASTMEDICALHISTORYwheniwassmall,ihadmeasles,chickenpoxandi*dliketoaskyouaboutyourpastmedicalwhoopingcough.butidon'tthinkieverhadrubellahistory.canyoumewhetheryouhavehadanyhaveyoueverbeeninhospitalizedforanything?orchildhooddiseases?forexamplehaveyoueverhadanoperationchickenpox,measles,mumpsorrubellawell,ihadmytonsilstakenoutwheniwasachildohno,itwasverysuddenhaveyouhadanymajorhealthproblemssincethenandyouraunts?doyouknowwhatkindofdiabetesyesjhavediabetestheyhave?dotheyhavetotakeinsulinortabletsorwhenwereyoufirstdiagnosedwithdiabetes?whataretheyjustonadietwereyoursimptomstheyjusttakesomepills,ithinkiwasdiagnosedwheniturned14.iwasalwaysyouaremarried,isee,haveyouanychildrenthirsty,tiredanddepreassedyes,aboyandagirlareyoureceivinganytreatmentforthisaretheyhealthyihavebeengettinginsulinshotseversinthyes,theyarehaveyouhadyourvaccinations3SOCIALHISTORYyesareyouworkingrightnowgoodno,ihavejustbeenlaidoffdidyourreferringphysiciangiveyoualetterfbrmeoh,iamsorry.whatwasyourjobyes,hereitisiwasamanagerforanimportandexportcompany2FAMILYHISTORYisee.wasitanofficejoborwereyouonyourfeetasfarasyouknow,arethereanyillnessesthatruninalldayyourfamily?iworkedbehindadesknonethatiknowof,doctorwasitmanagerial,didyouhavealotofresponsibilitynothinglikediabetes,highbloodpressure,heartyes,iwasinchargeofalargedepartmentdisease,stroke,cancer,mentalillnessoranythinglikeisee,quitestressful.now,tellme,doyousmokethat?yes,ido.unfortunately,quitealotohisee!myfatherhadaheartcondition,andihaveoh,really?howmuchtwomyauntswhohavediabetesallabout2packsadayandisyourfatherstillalivehowlonghaveyoubeensmokingno,heisn'tsinceiwasaboutfourteenhowoldwasyourfatherwhenhediedhaveyouevertrytoquitsmokinghewas68yes,ihavetriedseveraltimes.butwithoutsuccesswhatdidhedieoffwhataboutdriking?doyoudrinkhehadaheartattackyes,sometimeswithmyfriendsdidhesufferforalongtimewiththisheardcinditionhowmuchalcoholdoyoudrinkadaybeforehediedletsee.acoupleofglassesofbeeratlunchtime.awelivinginasmallapartment.weownit.butofwiskyintheevening.andabouthalfabottleofwinecoursewearestillpayingthemorgageonitwithmydinner4PRESENTCOMPLAINTSthat'squiteabit.howoldwereyouwhenyoustart4presentcomplaintsdrinking1-4-1oh,about17ir18,isupposewhat'stheproblemtodaywhataboutyourlivingconditions?wheredoyoulivecanyoutellmewhatyoursymptomsare1
2havehoueverhadthesecomplainsbeforearp/stabbing/colicky/migraine/blinding/stress-what'sseemstobringthisconditiononinduced/tensionwhendidyoustartfeelingpoorlytooth1-4-dialoguea(1-4-dialogueb)doyouhaveasharptoothachewhatseemstobetheproblematthemoment(today)isyourtoothachedull/throbbing/stabbing/pulsatingwell,ihavebeenfeelingsopoorlyrecently(illlately)isyourtoothsensitive/aching/tenderisee.feelingpoorly(ill).(now)whaldoyoumeanbythatlowerbackihavebeengettingveryshortofbreathisthepaininyourbackslowinonsetMonginhm…howlonghasthisbeengoingonduration/dull/diffused/aching/steady/constant/severe/forabout18months,ithinkprogressingpoorly/localised/crushing/deep/mildandwerethereanyothersymptomsbeforethenordidit(thiscondition)startquitesuddenlychestihadn'tnoticeanythingbeforethenisthepaininyourchestburningsoyouhaven't(didn*thaveanyof)experencethisdoyouhaveaconstrictingpaininyourchestsymptombeforebursting/choking/squeezing/griping/pressing/cruschinno,notthaticanremember,doctorg/sticking/jabbing/sharp/knife-isee.wasthereanythingthatseemstocausethis(havelike/fleeting/throbbing/du11/severe/stabbing/likeacausedthesesymptoms)weightonit/likeabandacrossitwell,nothing(no,not)really.exceptmaybeitgetsreallybadwhenigouptolondon(newyork)toseeabdomenmysisiterdoyoufellasharppaininyourabdomenlet'stakealook(tobeginwith).i'lllistentoyourheartdull/aching/gnawing/burning/cramping/colicky/diffusandlungstobeginwithed/Iocalised/recurrent/constant/flank/intermittent/stabbing1-4-5doyougetbloateda.whatcanidoforyoutodaydoyoufeelbloatedhowcanihelpyoumr.jonesduyouhaveanyheartburnb.whatdoyoumeanbythatdoyouhaveanyindigestioncanyoudescribethatinmoredetailc.whatareyoursymptomskidneysandurinarytractcanyoudescribethechangesthathaveoccurreddoyouhaveasharppaind.diditstartsuddenlyduyouhaveadullachedidyourconditionchangewithoutanywarningduyouhaveseverediscomforte.whatbringsitonbuming/stinging/nagging/nigging/splitting/flank/backwhatdoyouthinkcausesyourcondition/abdominal/steady/lowgradedoyouhaveslightdiscomfort5PAIN5painextremities1-5-1doyouhaveasharppaininyourshoulderheaddoyouhaveatinglingpaininyourhanddoyouhaveasplittingdoyouhaveashootingpaininyourfootheadache/throbbing/band-like/dull/aching/burning/shdull/burning/severe/pulsating/throbbing2
3doyouhaveweaknessinyourhands2doyoufeelanypaininyourtemplesdoyouhavenumbnessinyourarms3isthepainaroundyoureyesdoyouhavecramp4isthepainatthebackofyourheaddoyouhaveanacheonyourhand5doyouhaveanypaininyourforehead6doesthepainmovetoyourface1-57doyoufeelanypainaroundyourearsdialoguea(dialogueb)8doesthepainspreadtoyourneckdoyoufeelanypain9doesthepainseemtobecomeingfromyourneckoh,yes.quiteabit10doesthepaintraveltoyourshoulderscouldyoushowmewhereithurtsrighthere,doctor,inmychest1-6dialoguea(dialogueb)here,hm...isitalwaysjustinthatspottellmeaboutyourheadacheno,sometimesitmovesaroundtohereitcomesandgoesisee.whatkindofpainisit.canyoudescriethepaincanyoupointoutthepainfulareawell,mostofthetimeitfeelslikeacramp.butitseemstobeontherightsideofmyheadoccasionallyitissharpandstabbinghowlongdoestheheadachelastwhenyougetit(itdoesitcomeandgoordoyouhaveitallthetimecomes)well,itworseattimes.itseemstocomeovermeinitvaries.itcanbebetweenhalfanhourandfourorwaves.butmostlyifsthereallthetimefivehoursdoesitstartsuddenlyorbuildupslowlywhenyougetaheadache,doesanythingelsehappenitseemstobuildupgraduallyatthesametimewhatdoyoudowhenyougetthe(feelthis)painyes.oftenifeelsick(iamoftennauseous).sometimesiwe11,thereisn'tmuchicando.ijusthavetoputupactuallyvomit(throwup)withitdoestheheadacheeverupsetyoureyes,forexample,anddoesanythinginpaticularseemtobringthepaindoesyourvisiongetblurredonormakeitworseit'snotblurry.butigetflashinglightsthatseemstobewell,ifindgoingupstairsdifficult(itismoreintenseintherighteyewhenclimbingstairs).alsowhenihavetocoughorwhatdoyoudowhenyougettheheadachetakeadeepbreathit'sterriblelikeaknifestabbingmewhll,i*mnotususllyabletocarryonwithwhat(iususllyhavetostopwtatever)iamdoing,ihavetogo1-5-6toadarkroomandliedowna.canyoushowmewhereithertshaveyoufoundanytablets(medication)thatseemstob.couldyoudescribewhatthepainfeelslikehavehelpedc.howlonghaveyouhadthispainsometimesifitakeanaspirinearlyon,itseemstod.whendoesitcome,when,doesitgohelp.atothertimesnothingseemstohelpmuche.doesanythingrelievethesymptomsormakethemdoesanybodyelseinyourfamilyhavethistypeofaworthheadachef.doesthepainmovetoanotherpartofyourbodyyes,mymotherusedtosufferfrommigraineswheng.whatbringsitonshewasyoungercanyoudescribethe(characterofhe)pain.isit6HEADACHEstabbingormoreband-like,kindofpressing6headacheitthrobs.sortofstabbing,isuppose(guess)1-6-11doyoufeelthepainatthetopofyourhead1-6-63
4acanyoupointoutthepainfulareabhowlongdoestheheadachelastwhenyougetit8BODYTEMPERATUREANDSWEATccanyoudescribethepain8bodytemperatureandsweatdwhenyougettheheadache,doesanythinghappenatthesametime1-8dialoguea(dialogueb)ewhatdoyoudowhenyougettheheadachehaveyougotatemperature(hadanyfeverrecently)fhaveyoufoundanymedicanthatseemstohaveyes,doctor,ihavebeenfeelingquiteflushed(warm)helpedlatelygdoesanybodyelseinyourfamilyhavethistypeofisyourtemperature(constantly)highallthetimeorheadachedoesitgoupanddownitususllygoesup(itisuauallyhigher)atnight.butit7VERTIGOisstillhighevenduringthedayHowwouldyoudescribeyourdizziness?what*sthehighestandthelowestithasbeenintheIt'sasifIamfallingtotheleft.pastfewdayswhatdoesthediseasespellconstistforyou?Akindthehighestwas104.thelowestwas100ofimbalance.andwheredidyoutakeyourtemperature,underyourHowlongdoestheepisodeofdizzinesslast?armorunderyourtongue(orally)Sometimesanhour,sometimesawholeday.undermytongue(imeasureditorally)Inwhatbodypositiondoyoufeeldizzy?doyoualsohavetheshivers(chills)EverytimeIsquatorbenddownandtrytogetuptooyes,sometimesquickly.do(did)yourteethchatter(rattle)oraretheshivers(chills)milderthanthatDoyoueversufferfromdizziness?(getdizzy?)ohyes,theychatter(rattle).i'vebittenmytongueYes,quiteoften.severaltimesalreadyWhendoesthishappen?do(did)youtakeanythingforthefeverWhenIgetuptooquickly.aspirinDoyoufeelasifyouarefallinginacertaindirection?doesithelpNo,notreally.nonotreallyDoesthisdizzinessfeellikespinningorisitjustahaveyoubeenabroad(traveled)toanytropicalorkindofunsteadiness.developingcountriesrecentlyItfeelsmorelikespinning.yes,ijustcamebackfromtailandafewmonthsagoHowwouldyoudescribeit?Isitasiftheroomisisee.doyouperspiremorethanusualgoingaroundordoyoufeelasifit'syouthat'sgoingyes,alot,iamafraidaround.justwhenyourworkhardoralsoatothertimesItfeelsasifIamgoingaround.well,ineverusedtosweatmuch.butnowiseemstoDoyouhaveanyotherproblemssuchasringinginbreakoutinasweat(atthedropofahat)easily.mytheears.clothesoftengetsoakingwetYes,sometimes.doyoufeelshakyorweakatallHaveyouseenaconsultant(specialist)aboutthis?yes,practicallyallthetime'Yes,sheprescribedsomemedicationforit,butitdidn'thelpatall.9NAUSEAANDVOMITINGDoyouhaveanyassociatedsymptomslikeblurredDoyoujustfeelsick/nauseous/orhaveaactuallyvision.vomited?/thrownup/No,butIhaven'tnoticed(notthatIhavenoticed.)oh,Iamvomitinganditseems(Pmthrowingup)all4
5thetime.WhenIamrest,butitisworsewhenItrytodoWhendiditallstarted?anything.Abouttwomonthsago.Canyoulieflatinbed?Andhowoftendoesthishappen?Oh,no.Aboutonceaday,sometimesmore.Howmanypillowsdoyouuse?Whenareyousick?Isitinmorningorafteryou'veThree.eaten.Doyoueverwakeupnightfeelingshortofbreath?Well,"isn'treallyregular.Yes,Ido.Butdoesitgetbetterorworseifyoueatsomething?(IffrightensmebecausewheniwakeupfeelingasifWorse,Ithink.icann'tbreath.Whenyouvomit,doyoubringupdigestedfood,Whatdoyoudowhenthishappens?Imean,doyouundigestedfoodorbile?sitorstandup,doessomemovementhelp?Oh,itisusuallymorelikebileIfIsitup,ithelpsalittle.whatcolourisit?Green,black,yelloworred?Letmelistentoyourchest.IcanhearfewcracklesItseemstobeasortofyellowishgreencolor.anditsoundsabigwheezy.Doesiteverhavebloodinitorlooklikegroundcoffee?DialogueBno,neverHowlonghaveyouhaddifficultybreezing?.Doyoubelchalot/burpalot/orhaveabad/anasty/Scincelastweek,doctor.tasteinyourmouth?Isitverybad?Well,yes,doctor.Idobelchalotand1seemtoYes,IfeellikeIcan'tgetenoughair.sufferfromalotwindjustlately,/andIhavehadaWhat'sharder,breathinorbreathout?lotofgaslately/It'shardertobreathin.Areyoushortofbreath,whenyouareresting,or10DYSPN(O)EAonlywhenyouaredoingsomethingphysical.DyspneaAlittlewhenIamresting,butit'sworsewhenItryDoyouhaveanydifficultybreathing?todoanythingphysical.What'sharderbreathinginorbreathingout?Canyoulieflatinbed?Areyoushortofbreathwhenyouareresting?Oh,no.Canyoulieflatinbed?Howmanypillowsdoyouuse?Isitrelievedbysittingupinbed?Three.DoyouhavetostopfrequentlywhenyouclimbtheDoyouoftenwakeupnightfeelingshortofbreath?stairs?Yes,Ido.It'sscaresmebecauseIwakeupfeelingasHaveyoueverhadanybreathingtests?ifIcan'tbreath.Whatdoyoudowhenthishappens.Imean,doyouDialogueasitorstandup?DoessomemovementhelpyouHowlonghaveyouhaddifficutlybreathing?breatheeasier?Sincelastweek,doctor.IfIsitup,ithelpsalittle.Isitverybad?Listentoyourchest...IcanhearafewcracklesanditYes,IfeelasifIcan'tgetenoughair.soundsabigwheezy.Whichismoredifficult,breathinginorbreathingout?Itishardertobreathingin.howlonghaveyouhaddifficultybreathing?/howAreyoushortofbreathwhenyouarerestingoronlylonghaveyoubeenshortofbreath?whenyoudoingsomething?i*vehaddifficultybreathingforabouttwoweeks.5
6whenisyourbreathingmostdiffcult?sometimenow?iwheezeintheearlyhours.I'vehaditforsometime,doctor.whichismoredifficult,breathinginorbreathingout?Doyoucoughalot?breathingoutisharder.Yesalot.areyoushortofbreathwhenyouarerestingoronlyDoyoubringupphlegm,orisitadrycough?whenyouareworking?Ibringupquiteabitofphlegm.IamafraidImighti*mshortofbreathwheni*mworking.haveasthma?canyoulieflatinbed?/canyousleeponyourback?Whatisthephlegmlike?yes,icansleeponmyback.Whatdoyoumean?canyoueverwakeupatnightbecauseyouareshortCanyoudescribeformewhatcolouritis,whetheritofbreath?/isyoursleepdisturbed?iswhite,yelloworgreenish,andwhatisitfoamy,yes,ieakeupseveraltimesbecausei'mshortofthickandsticky?breath.Yesitisyellowishandfeelskindoflikeajelly.whatdoyoudothen?Doesithavestrangesmellortaste?iusuallygetupandwalkaroundwhenithappensNoIdon'tthinkso.11COUGHHasthereeverbeenbloodinit?DialogueAYes,justonceInoticedsomebloodinit.Doyouhaveacough?Haveyoutakeanymedicationlately?Ihaveacough,butIalsoseemtowheezealot.YesIwasonsomemedicationtothinmyblood.Isthisarecentsymptom,orhaveyouhaditforsometimenow?Yes,itsmellsverybad.Fvehaditforsometime,Doctor.Itisfrothy!Doyousufferformcoughingfits?Fvehadthiscoughfor3weeks.Yes,alot.Yes,Ibringupalotofphlegm.Doyoubringupphlegmorisitadrycough?IfIsituporusetwopillowsIfeelbetter.Ibringupquiteabitofphlegm,IamafraidImightIt'sabarkingcough.haveasthma.Whatisitlike?12HEARTWhatdoyoumean?heartsymptomsCanyoudescribethephlegmforme?Whatcolorisit?AIsitwhite,yellow,orgreenish,andisitwhatseemstobetheproblematthemoment?frothy/foamy/orsticky?iseemtobegettingveryshortofbreathnowadays,Yes,it'syellowishandfeelskindoflikejelly?soithoughtitbesttocomeintoseeyou.ialsofeelaDoesithaveastrangesmellortaste?tightnessinmychest.No,Idon'tthinkso.howlonghasthisbeengoingon?Hasthereeverbeenbloodinit?itseemstohavebeengettingworseoverthelastfewYes,justonceInoticedsomebloodinit.weeks.Haveyoutakenanymedicineortabletslately?areyoushortofbreathallthetimeorisitjustwhenYes,Iwasonsomethingtothinmyblood.youwalkupthestairs?well,itishardworkgoingupthestairs,thepainfeelsDialogueBlikeaknife.Doyouhaveacough?doesthepainmovetootherareaaswell?Ihaveacough,butIalsoseemtowheezealot.yes,itmovestomyneck,myleftarm,mybackandIsthisarecentsymptomorhaveyouhadformyshould.6
7doyoueverfeelsickorsweatywhenthathappens?oh,myfeetfeelmuchbetterandtheyaren'tswollenwell,idon'tfeelsickbutioftenbreakoutinasweat,inthemorningdoyoueverfeelthatyourheartbeatsusuallyfastorslow?haveyoueverhadanyheartproblems?yes,sometimesitbeatsreallyslowly,thenfromtimei'veneverbeendiagnosedwhitangthing,butithinktotimeitskipsabeat,thencontinuestobeatverysomethingcanbewrongmyheart.rapidly.whatseemstobetheproblemwithyourheart?canyoutapoutwithafingerwhattherhythmfeelsitbeatsirreguallyespeciallywhenismoke.liketoyou?..good,haveyouhadanyswellinginwhatkindofpaindoyougetduringyouexercise?youankle?igetpressureinmychestsometimeswhenihavetoyes,bothmyfeethavebeensomewhatswollen.walkalongdistance.doesthisgodownovernightoraretheystillswellondoyouoftengetshortofbreath?inthemorning?absolutely,iamalwayshortofbreathwhenigooh,myfeetfeelmuchbetterandtheyaren'tasupstair.swolleninthemorning.doyoueverfeelsweatywhenthishappens?yes,ibreakoutinareallybadsweatwhenmychestBhurts.canyoutellme,...whatareyouscomplaints?wheredoesthepainmove?iseemtobegettingveryshortofbreathlately,alsoidownmyleftarm.feeltightnessinmychest,soithoughtitwouldbeandhaveyouhadanyswellinginyourfeetorankles?wisetocomeinandseeyou.yes,myanklesseemtobeswollenallthetime.howlonghasthisbeengoingon?doyourfeethurtallthetime?itseemtohavebeengettingworseoflastfewweeks,yes,thepainisfairlyconstant,butithelpswheniputareyoushortofbreathallthetimeoritisjustwhenmyfeetup.youexertyourself?well,thepaingetsworsewheniexertmyself,itfeels13BODYWEIGHTANDDIETkindoflikeaknife.What'syourappetitelike?doesthepainradiatetootherareasaswelloristheAreyouonaspecialdiet?painlocalised.(Haveyoueverfollowadiet?)no,itmovestomyneck,myleftarm,mybackand(Haveyoutriedtoloseweight?)myshould.Haveyouhadyourcholesterolchecked?doyoueverfeelsickorsweetywhenthishappens?Isyourweightsteady?well,idon'tfeelsickbutioftenbreakoutinasweet,doyoueverfeelthatyourheartbeatsunusuallyfastTellme,what'syourappetitelike?/how'syourorslow?appetiti?yes,sometimesitbeatsreallyslowly,thenfromtimeSometimesit'sgood,butatothertimesIdon'tfeeltotimeitskipsabeat,thencontinuestobeverylikeeatingatall.rapidly.Howdoyoufeelaboutyoureatinghabits?/describecanyoutapoutwithafingerwhattherhythmfeelsyoureatinghabitstome?liketoyou?..good,haveyouhadanyswellinginyouwell,Iusuallyeatfiveorsixtimesaday.Lotsofankles?foodsandvegetables,butwhenIamanxiousyes,bothmyfeethavebeensomewhatswollen./nervous/1can'teatatall.doesthisgodownovernightoraretheystillswollenHaveyoulostorputon/gained/anyweightrecentlyinthemorning?ordoesyourweightstayatsame?7
8Fvebeenputting/gaining/onquiteabit/lot/of-Isitmixedinwiththestoolorisitjustthereontheweightlikely.paperwhenyouwipeyourself?Howmanypoundshaveyougaindoyouthink/-Itseemstobemixedinwiththestool,Doctor.you'vegained?-Isee.andwhenyouareconstipated,doyoutakeAbout10poundsorso.laxative,ordoyougiveyourself(use)anenema?Overhowlonga/what/periodoftimehasthis-IfIcan'tgoforthreedays,onlythelaxativehelps.happened?-Doyoufeelbloatedwhenyouareconstipated?Sinceaboutcharismas,sointhelast6months.-Yes,occasionally.ButthelaxativehelpswiththatAreyoutryingtodoanythingtocontrolyourweight,too.forexample,areyouonadiet?DoyouhaveanyproblemswithexcessivewindorYes,butitdoesn'tseemtowork.belching(gasorburping)?ArethereanyfoodsyoudislikeoristhereanythingNo,notparticularly.thatyouparticularlyliketoeat?Ieatlotsofpastadishes,butIcan'thaveanything1-14-5withnutsinthembecauseIamallergictomostkindsAofnuts.Isitactuallypainfultohaveabowelmovement?=Doyoureatinghabitschangeforanyreason?Doesithurtwhenyouopenyourbowels?Yes,IeatquiteabitmorewhenIfeelgood.BHaveyouevertriedtakinganylaxativesthatyoucanIamlosingmyappetiteabit.getatachemist's?=DoyoutakeanythingforyourYes,Iamgettingverythin.bowels?Ihavelost20pounds.CI'dsay,duringthelast3monthsorso.Doesyourstomacheverfeeldistended?=DoyouYes,Ican'tstandasightofmeat.everfeelbloatedwhenyouareconstipated?D14BOWELMOVEMENTSDoyouhavewindmovingaroudinyourbowels?=BowelmovementsDoyoufeelgassy?1-14EdialogueADoyoupasswind?=Doyoubreakwind?-Doyouhaveregularbowelmovements?F-No,(Yes,but)sometimesIgetconstipatedandDoyouhaveatendencytowardsflatulence?=DosometimesIhavediarrhea.youeversufferfromexcessivewind?-Whenyousayyouhavediarrhea,doyoumeanthe15BLOODstoolisveryloose,orthatyouhavetogotothebloodtoilet(bathroom)morefrequently?DialogueA:-Ihavetogofourorfivetimesaday.A:Soyousaythatyouarehavingproblemswith-Whenyouhavetogo,doyouhavetogoquickly?bleedingorbruising?-Yes,Ihaverealproblemsholdingit.B:YesIam.-Couldyoudescribeyourstool?A:Canyoutellmewhatyoumeanbythat?Doyou-Thelasttimeitwaslooseandwatery,butverydark.bleedorbruiseeasily?-Doyouhaveanyproblemsflushingitdownatall?B:B:Yes,everytimeIscrapemyselforbumpinto-No,Ihaven'tnoticedanythinglikethat.somethingIgetbruised.-Hastherebeenanybloodormucusinthestool?A:Haveyoualwayshadthisproblemorisitrecent-Yes,Ihavenoticedsomeblood,butnomucus.development?8
9B:1noticedtheproblemstartedaboutthetimeIB:1don'tlikeneedlessoIdon'tgiveblood.ButIstartedshaving.neededatransfusionafteracaraccidentafewyearsA:Doyourgumsbleedwhenyoubrushyourteeth?agowhenIwas15.B:Yes,quiteabit.A:DoyourememberhowmanyunitsofbloodyouA:Doyouhaveanytroublestoppingthebleeding?received?B:Oh,yes,evenfromthemostminorcutsB:No,Idon'tremembersorry.A:Howlongdoseittaketostopthebleeding?A:Doyouknowwhatyourbloodtypeis?B:Atleast10or15minsB:Ithink,it'sABnegativebutIamnotsure.A:Arethereanyothermembersofyourfamilywithbleedingtendencies?16MEDICALEXAMINATIONB:No,nothatIknowof.16>medicalexaminationA:Haveyoueverneededthebloodtransfusion,orhaveyougivenbloodrecently?1NowMrJacob,I'dliketoexamineyou.IjustwantB:Idon'tlikeneedles,soIdon'tgiveblood.ButItocheckoneortwothings,yourheartandyourlungsneededatransfusionafteracaraccidentafewyearsandabdomen.WouldyoujusttakeoffyouragowhenIwas15.clothes/just/downtoyourunderwearandpulonthisA:Doyourememberhowmanyunitsofbloodyougownwiththeopeningattheback.received?2Hopon/pleasegeton/thetableforme,canyouB:No,Idon'tremembersorry.manageorshall1giveyouahand?/canyoudoitA:Doyouknowwhatyourbloodtypeis?yourselforwouldyoulikemetohelp?B:Ithinkit'sABnegativebut1amnotsure.3Right,givemeyourwrist,willyou.IamgoingtoDialogueBtakeyourpulse.Thatisfine.A:Soyousaythatyouarehavingproblemswith4Nowlet'stakeyourbloodpressure.Willyoubleedingorbruising?straightenyourarmforme,please.B:YesIam.5Nowlet'shavealookatyoureyes.Lookupforme.A:Canyoutellmewhatyoumeanbythat?Doyouplease.bleedorbruiseeasily?6Letmecheckthereflexesinyourarmsandlegs.B:Yes,everytimeIscrapmyselfforbumpingtosthIRelax.getbruised.7Turnyourheadtotherighttolookatthewall.IA:Haveyoualwayshadthisproblemorisitjustwanttocheckthepulseinyourneck.recentdevelopment?8Letmefeelyourwindpipe...LetmejustfeelyourB:InoticedthattheproblemstartedaboutthetimeIglands.That'sfine.startedshaving.9Stickyourtongueoutforme,please.OpenyourA:Doyourgumsbleedwhenyoubrushyourteeth?mouthandsay"ahh”.B:Yes,quitealot.10Right,nowIwanttolistentoyourheart.JustA:Doyouhaveanytroublestoppingthebleeding?breatheoutquietlyB:Oh,yes,evenfromthemostminorcuts11NowsitforwardwhenIlistenattheback,holdA:Howlongdoseittaketostopthebleeding?yourbreath....Good.Nowlet'slistentoyourlungs.B:Atleast10or15minutesTakedeepbreathsthroughyourmouth—in....out...A:Arethereanyothermembersofyourfamilywithkeepgoing.bleedingtendencies?12Fdliketofeelyourabdomen.PutyourarmsB:No,notthatIknowof.downbyyoursideandletyourtummy/stomach/A:Haveyoueverneededthebloodtransfusionorrelax...that'sit.Arethereanyplacesthataretenderhaveyougivenbloodrecently?orpainful?NowIwanttocheckyourliverand9
10spleensotakedeepbreathin,holdit...fine.locationofthelymphnodes,sopleasedon'twashthe13I'djustliketoexamineyourprostateandrectum.marksoff.Nowthiswillbeslightlyuncomfortable,butitbeforetheinjection,youwillneedtoalieinadarkshouldn'thurt.Liedownonyourleftsideandbendplaceforforty-fiveminuteswithyoureyesclosed,yourkneesrightuptoyourchest...fine.Iamgoingonlyaftertheinjectioncanyouopenyoureyes.toinsertafingerintoyourrectum.Don'tworry,youwon'tloseanycontrol.Bl.youwillbegivenanintravenousinjection,makea17ISOTOPESCANNINGfist,thenletitgo.thisinjectioncontainsasubstance1,youwillreceiveanintravenousinjection,makeatomakenecessaryorgansvisibleonthetightfist,nowopenit,thisinjectioncontainsthemachine.therellbesomewaitingtimebeforethemedicinewhichcanbeseenbythemachinesothatitactualexamination.Thisisnecessarysothatthetestispossibleforustoscanyourorgan,youhavetosubstancecanreachtheappropriateorgan.waitsothemedicinecanreachtheorgan.youmust.youmustremaincompletelystillduringthenotmoveduringthescan,wewillsenttheresultstoexamination,theresultswillbegiventoyourregularyourdoctor.physician.2,haveyoudrunkanythingtoday?youmustdrink2.haveyoudrunkanyliquidstoday?you'llhavetofourglassesbeforethescan.wewillgiveyouawaterdrinkabout4glassesoffluidsbeforethetabletduringthescan,afterwhichyouwillhavetoexamination,you'llalsobegiventhesubstanceurinatemoreoftenthenusual.doyoutakeanythingtowhichwillmakeyouhavetogotothebathroomkeepyourbloodpresuredown?frequently.Whatbloodpressuremedicationareyou3,a,beforeyougettheinjectionyouneedlieonyourtaking?backfortenminutes.3.A)beforereceivingtherejection,youshouldlieonb,nowyouhavetoinhaleavapourforthetest.thisyourbackfor10minutes,hasnotasteorsmell,you'llneedtositinfrontofanNowyoumustinhalethespray.itresembleswaterinhaler,you'llgetaclipforyournosesothatyouvapourandhasnotasteorsmell,inthesecasesyou'llbreaththroughyourmouth.havetositinfrontofinhaler,we'llclipyournose4,beforetheexaminationyouneeddrinkalitreofshutandyouwillhavetobreathethroughyourthefluidovertheperiodoftwehours.beforewecallmouth,youyoushouldgotothetoilettoemptyyour4.thewaitingtimeisabout2hours,duringwhichyoubladder,otherwisewecann'tscanyourhipcorrectly.shoulddrinkapproximatelyaliteroffluid,pleasego5,you'llhavetodrinkasweetenedsolutionwhichtothebathroombeforeyouarecalled,sothatyourwillcontractyourgallbladder,thistastesverysweetbladderwillbeempty,otherwisewewillnotbeableandinsomepeoplecausesdiarrheatomakeapreciseexaminationofthepelvicbones.6,mycolleagethecardiologistwillexplainthe5.youwillhavetodrinkasucrosesolutionstoprocedure,afteryouaregiventheisotopeinjectionconstrictyourgallbladder,itisverysweet.formanyyouhavetoconsumefattyfoodordrink,suchaspeopleitmaycausediarrhea.milk,cheeseorsandwish.thisissothatthemedicine6.thecardiologistwillinformyouaboutthepassesthroughyourliverquicklyforustogetcorrectprocedure,afteryouhavereceivedtheisotopepictureofhowtheheartmusclearesuppliedwithinjection,youshouldeatordrinksomethingblood.containingfat,suchascheese,milkorsandwich,this7,you'llgetfoursmallinjectionwhereyouhaveisnecessaryinordertostimulatethesubstancebeingchangesonyourskin.welltakethreepitures.thelastpastthroughtheliver,sothatwecanmakeanwillbetakenin24hours*time,wewillmarktheaccurateimageofbloodsupplyofyourheartmuscle.10
117youwillbegivenfoursmallinjectionsaroundthebronchodilators,toreducebronchialspasmsaffectedareasofyourskin,uwewilltakescans3diuretic,tohelpthepatienttopreducetheurinetimes,thelastofwhichwillbe24hourslater,wemucolytics,toliquefyviscidbronchialmucuswillmarkthelocationofindicatedlymphglandwithsedative/tranquilizers,toinducetranquilityorsleepastain,pleasedonotwashthisoff.spasmolytics,torelaxsmoothmusclesandrelieve8,beforereceivinginjection,youwillhavetolieinacrampsdarkroomwithyoureyesshutforabout45minutes,pleasedonotopenureyesuntilaftertheanalgesic,torelievepaininjectionantibiotics,toeliminateinfectionsantacids,toneutraliseacidinthestomach18PRESCRIPTIONSantipyretics,tobringthetemperaturedownprescriptionantihypertensives,tobringthebloodpressuredownyouseemtohavealocalizedskinrashcausedbyaemetics,tohelpthepatientstovomitbacterialinfection.thismeansyouwillhavetotakeantiasthmatics,totreatthebronchialasthmaasomeantibiotics,areyouallergictoanymedicine?vesseldilates,todilatebloodvesselsandimproveYes,actually,IhadquiteabadreactionsoncewhenIcirculationtookpenicillin.ifeltachokingsensationandmytonguewasbadlyswollen.ican'tsleepatnightandi'mtiredwhenigetupintheOk,thenI'llprescribeanantibioticswithoutmorningpenicillin,you'llhavetotakeonetablet3timesaday,mylittlegirlisalwaysscratchingherbottom,andipreferablyimmediallyaftereating,havenoticedsmallwormsinherstool.IstheresomekindoflotionthatIcanuseonmyskin?myanklesareswollen,i'mbloatedaroundmyYes,Icanalsoprescribeananti-inflammatorystomachintheeveningointmentorsometalcumpowder,bothshouldhelpicoughalotbutican*tseemtocoughupphlegmreducingtheburninganditchingsensation,!ioftenfeeldizzyandihaveheadaches,myvisionisrecommendtheointment,butI'llprescribewhichevergettingworse,mybloodpresureusuallyhighwhenyouprefer.Whichwouldyouratheruse?it'scheckedThenI'lltaketheointment,asyousuggested.Youshouldapplyitwhenveryouneedto.doyou20SIDE-EFFECTSOFDRUGSfeelthatyouneedsomepain{blocked}ers?3sideeffectsofdrugsYes,thatwouldquitehelpful,ihavn'tbeenabletodo232anythingsincethisstarted.ithurtssobadly,1.Youprescribedsometablets/pills/formywell,thatshouldclearitup,ifeverthinglookspneumonia,Bytheeveningmyfacewasflushedandgood,youwon'thavetocomebackagain.howeverifitching.AndIhadcome/broke/outinarash.thesymptomsdon*tgoawayafteraweek,makesure2.IcamedownwiththeflusoItooktheaspirinasyoucomebackandseemeagainyousuggested,however,bythenextmorningIhadanupsetstomach,I'mafraidtocontinuewithit,butI19THERAPEUTICEFFECTSOFDRUGSamstillrunningafever.therapeuticeffectsofdrugs3.I'vebeenfeelingdizzysinceIstartedtakingthenewbloodpressuremedicine.WhenIbenddown,antiemetics,tostoporpreventvomiting,FmafraidTHfalloveranthelmintics,toeliminateworms4.FvebeenfeelingsicksinceIstartedtakingthisanti-inflammatorydrugs,todecreaseinflammation,newmedicine,I'vehadanupsetstomachsincethen.antitussives,tostopcoughing,11
12233Takethiscapsulewithsomewater.1.youprescribedsometabletsformypneumonia,Dropsomemixtureonasugarcubebytheeveningmyfacewasflushedanditching.AndShakethemixturewellbeforetaking.Ihadcomeoutinarash.InsertoneofthesesuppositoriesintothevaginaOhFmafraidyoumustbeallergictothatmedicine,beforegoingtobedFilprescribesomethingelsethatshouldn'taffectyou.Rubathinlayerofthiscreamonyourskin2.IcamedownwiththeflusoItooktheaspirinyouUsethreedropsofthiseyedropseveryeveningsuggested,however,bythenextmorningIhadanApplysometalcumandpowdertoyourskinupsetstomach,I'mafraidtocontinuewithitbutI'mMix15dropsinacupofwaterandgargletwoorstillrunningafever.threetimesaday.Aspirinsometimesaffectsthestomach,Ithinkyoushouldtakeparacetamolinstead,itdoesn'tcause22GENERALQUESTIONSstomachproblems.unit3obstetricsandgynecology3.TvebeenfeelingdizzysinceIstartedtakingthe1generalquestionsnewbloodpressuremedicine.WhenIbenddown,3-1FmafraidI'llfallover.Yourpressurehascomecouldyoutellmewhenyourlastperiodwasdownalittlelow,andthat'scausingthedizziness,soitwasabout3weeksagowe'lladjustthedosageofyourtablets.doyouhavearegularcycle4.TvebeenfeelingsicksinceIstartedtakingthisyes,it'squiteregular,itcomesaboutevery28daysnewmedicineformyheadache.Tvehadanupsetandhowlongdoyourperiodslaststomachsincethen.usuallyabout5or6daysOhdear!Fmsorry.We'llhavetochangethewouldyousaythattheywerepainfultablets/pills/toputa/stop/tothenausea.igetsomediscomfortespeciallyduringthefirst2or3days,butit'snottoobad21ADMINISTRATIONOFMEDICATIONwouldyousaythatyourperiodsarequitelight,AdministrationofMedicationaverageorheavyiwouldsaytheyareaboutmoderate,doctorTakethistablethalfanhourbeforemeals.doyoufindyouareusingalotofpadsSwallowthistabletwithoutchewing.no,icanusuallyjustmanagewith3or4adayTakeapinchofthispowderandmixitwithsomenow,haveyouhadasmeardonewithinthelast3water.yearsApplyathincoatofthisointmenteveryeveningandihadonedoneabout5yearsago,doctorthencoverwithawetdressing.doyouremembertheresultsofitDipacottonbudinthistinctureandapplyittoyouryes,theysaiditwascleargums.doyouknowhowoftenyououghttobecomingPouranampuleofthissolutionintoboilingwater/shouldcome/forasmeartestandinhaleitforfiveminutes.ithinkit'saboutevery2or3yearsThisisabittertablet,sotakeitwithsomesortofyes,that'sright,althoughifthereareanyjuice.abnormalitiesonanyofthesmeartestsyoumust/should/comebackmoreregularlythanthat,doyouIfyouareunabletoswallowthistablet/pill/,breakithaveanypainorswellingyou'venoticedinyourinhalforcrushitintoapowder.breastsPlacethispillunderyourtongueandallowittowell,idon'thaveanylumps,doctor,buti'vedissolve.sometimesnoticethattheygetabitsore,especially12
13justbeforemyperiod,also,sometimestheyfeelabitrecently./little/lumpy,butwhenicheckthemafewweeksD:haveyoubeenpassinganyclotsinthem?latertheyallseemtohavegoneaway.P:well,thelastfewtimestheyhavebeenoneortwoquite/pretty/bigclotsandsometimesit'sbeen23GYNAECOLOGICALCOMPLAINTSsoakingrightthroughthepadsandintomyunderwear,andi'vehadtogoandchangequickly,it'sgynecologicalcomplaintsbecomingreallyveryembarrassing.dysmenonheaD:isee.areyourperiodsverypainfulatall?PMTP:well,they'reworsethantheyusedtobe,butthe1worstthingisreallyjustthisterriblebleeding,it'sdysmenorrheacausedmeawfulembarrassmentandtrouble.amenorrheamenorrhagia3-2-CleukorrheaD:couldyoutellmewhenyourlastperiodwas?metrorrhagiaP:welldoctor,they,vebeenabitirregular,dyspareuniasometimesthey'vecomingeverytwoweeks,prolapsesometimesiamnotgettinganyfor6or7weeks,andhypermenorrheawhentheydocometheycanbeterriblyheavywithfloodingandpassingclotsforthefirstcoupleofdays,3-2-Ai'mhavingtousesanitarytowelsandtamponsD:whatseemstobetheproblem?sometimes,andtheycanbeveryverypainfulfortheP:overthelastafewmonths,myperiodshavebeenfirst2or3days,andfortheweekbeforehand.gettingterriblypainful.D:haveyourperiodsalwaysbeenirregularorhasD:isthisanewthing?thisbeensomethingrecent?/didthisjuststart?/P:myabdomenisalwasysalittlebitsoreinthefirstP:no,theywerequiteregularupuntilaboutayearcoupleofdays,butoverthelastfewweeks,ihaveago,andthentheygraduallybegantogohaywire.beengettingreallysore.ihavebeengettingthisD:doyougetanybleedinginbetweenyourperiods?terriblecrampyfeelinginmytummy/stomach/andP:yes,isometimesgetalittlebitofspottingofbloodsomebackacheaswell.it*sbeencomingonbeforejustinthemiddleofmyperiodsthebleedingbegins/itstartsbeforethebleeding/andifsbeensobadthatihadtohavesomedaysofffrom3-2-Dworkoverthelastfewmonths.i*vealsogotanotherD:doyoueverfindituncomfortabletohavesex?problem,igetsoup-tightjustbeforemyperiods,iP:yes,doctor,thelastfewmonthsit'sbeenquitefeelasthoughicouldmurdereveryone.painful.D:thatsoundstypicalofPMT/PMS/-pre-menstrualD:doesithappeneverytimeorjustoccasionally?tension.it'sdifficulttotreatbutsomepeopleareP:almosteverytime,igetthisreallydeepachehelpedbyvitaminB12oreveningprimroseoil.thereinside,ithasbecomesobadthatwehaven'tbeenaresomeself-helpgroupsthatyoucouldjoin,theabletodoitforthelastfewweeks.receptionistwillgiveyouapamphletifyouaskher.3-2-E3-2-BD:canyoutellmewhattheproblemis?D:whatseemstobetheproblem?P:well,doctor,igotthisdischargefromdownbelow.P:myperiodsusedtobequite/fairly/light,doctor,D:canyoudescribeittome?whatcolorisitforbuttheyseemtohavebeengettingmuchheavierinstance.13
14P:well,it'ssortofyellowishbutsometimesit4pregnancybecomesbrown.3-4-AD:isthedischargefoulsmellingatall?D:whatcanIdoforyou?P:well,sometimesitsmellsquitestrong,doctor.P:well,Idon'tseemtohavehadaperiodforseveralD:doyouhaveanyburningorstingingwhenyougomonthsnow,tothetoilet?D:howlonghasitbeensinceyourlastperiod?P:itsometimesstingswhenispendapenny/urinate,(Whenwasyourlastperiod?)pee/P:well,Ithinkitwasabout2or3months,butD:isyourvaginaitchyorsore?they'vealwaysbeenalittleP:yes,abit.bitirregularD:haveyouevergonethislongbeforewithout3-2-Fhavingaperiod?P:doctor,i'vegotsomethingdownbelow.P:no,theyalwaysseemtocomeonafterabout6or7D:wheredoyoumeanexactly?showme.mm.isthisweekslumpthereallthetime,oronlysometimes?D:areyousexuallyactive?P:itonlyseemstocomeonafteri'vebeentotheP:yes,doctortoilet.D:areyouusinganykindofcontraception?D:isthatafteryou'vebeentopassurineorafteryouP:Yes,healwaysusesacondomhaveabowelmotion?D:haveyoueverhadanyaccidentsorperhapsP:well,sometimesbothbutmoreafteri'veopenmyforgottentouseacondom?Dobowels,doctor.youthinkyoumightbepregnant?D:areyouabletopushthislumpbackup?P:well,maybe,becausetherewasanepisodeafewP:sometimesicanpushitbackup.weeksago,nowIcometoD:doesitevercomedownandyouarenotableto?thinkofit,whenthecondomsplit.Butwedidn'tP:no,doctor,itcanalwaysbepushedbackup.thinkitwassoimportant,becauseitwasjustbeforemyperiodbegan.24PHYSICALEXAMINATIONphysicalexamination3-4-Bifyoucanjustpop/step/go/behindthecurtainsandD:howlonghasitbeensinceyourlastperiod?takeyourtrousersandunderwearoff/takeyourP:cometothinkofit,about2or3months.slacksandunderwear/andcoveryourselfwithaD:doyouthinkyoumightbepregnant?blanket,i'llberoundinaminute.P:well,Ithinkit*spossible,doctor,thelastfewjumpupontothecouch,/youcangetonthecough/weeksI'vebeenfeelingifyoujustslidealittlebitfurtherdownatableandifreallyquitequeasyinthemorning,andFvegoneoffyoupullyourkneesuptowardsyou,now,letyoursomeofmyfavoritekneesfallapartfoods.Tvestartedeatingthemostpeculiarstuff.Ikeepyourkneesasrelaxedasyoucan.putyourfeetneverusedtolikewideapartinthestirrups,ifyoujusttryandrelaxtomatoesandnowIcannevergetenoughofthem.yourbottomdownintothebedasmuchasyoucan,Fvealsonoticedthatmythatkeepsyourmusclesrelaxedandmakesitmuchbreastsarereallytenderliketheygetbeforeperiod.morecomfortableforyou.D:haveyoufeltsickorbeensickatalljustletmeknowifthishurtsatallP:well,IsupposeIshouldhaveguessedmyselfthatImightbepregnant,25PREGNANCYbecausethelast3morningsFvebeenfeelingreally,14
15reallysickandIsometimestheycantellactuallyvomitedthismorning.Tvealsobeenfeelingwhetherit'sgoingtobeagirlorboyfromthescanterriblytiredandIP:I'mnotreallysureIwanttoknowkeephavingtorushtotheloo/bathroom.Tvealsofeltquiteonedgeand26PASTPREGNANCIESanxious.Theotherthingisthatmybreastsseemtopastpregnancieshavegot/gottenbigger.3-5-AFvealwaysbeena32BcupupuntilnowandIwouldD:isthisyourfirstpregnancyswearthatthey'reP:nogettinglargerD:howmanytimeshaveyoubeenpregnant?D:let'sdoapregnancytestandwellseewhatitP:ihavebeenpregnantsixtimesshows.....thepregnancyD:howmanychildrendoyouhave?testfromthebloodhasshownthatyouarepregnant,P:i*vegot3children.canyourememberD:weretheyallnormaldeliveries?exactlywhenthefirstdayofyourlastperiodwas?P:ihadoneofthembyacesareanbecauseihadP:notexactly,butIthinkitmusthavebeenabout8problemswiththedelivery,weeksago.buttheothertwowerenormaldeliveriesD:well,workingitoutroughlyfromthefirstdayofD:whataboutmiscarriages?yourlastperiod,itP:well,ihadonemiscarrigequiteearlyonbeforethelooksasthoughyouwillbehavingyourbabyatthefirstchild,andthenendofOctober.mythirdpregnancyendedinstillbirth,ialsohadatubalpregnancywhich3-4-CneededanoperationD:haveyoufeltthebabymoveatallD:haveyouhadanyterminations/abortions?P:well,justalittlebit.IfeltthissortofflutteringP:nofeelinginmyD:doyouhaveanyproblemsatthemoment?tummy/stomach,thefirsttimeIthoughtitwaswindP:i'venoticedthatmyhandsandfeetaregettingabitbutthenitcamebackswollen,andmyagain,soIthinkitmusthavebeenthebabykicking.ringsaregettingtight.D:haveyouhadanyproblems,anyburningorD:howdidyoufeedyourchildren?breastorbottle?stingingwhenyoupassurine?P:ibreast-fedallofthem,butonlymanagedforP:yes,it'sveryuncomfortableattimes,andFvealsoaboutthefirst3monthshad/alsohave/thisandafterthat,webegantotopthemupwithbottledischargefromdownbelowandit'sbeengettingmilk.itchyandreallyunpleasant.D:ok,that'sgood,wejustneedtodoalittleinternalD:well,wehavetohavealookdownthereandwe'llexaminationnow.probablytakeaswabbutitsoundsasthoughyoumighthaveatouchofthrush3-5-BwhichissomethingD:haveyoueverbeenpregnant?commoninpregnancyandquiteeasilysortedP:yesout/fairlyeasilytakencareof.D:doyouhaveanychildren?Haveyouhadyourultrasoundscanrecently?P:yes,i'vegot2boys.P:no,I'mdueforonenextweek.D:howoldarethey?D:theycanshowwhetherthebabyisgrowingwell.P:3and5.15
16D:whenyourolderchildwasborn,doyourememberbutafterthatitifhewasearlyorlaleorreallybecametoopainfulandIhadtohaveanontime?epiduralP:well,hewasabout4weeksearly,doctorDidyourstartlaborbyyourself,ordidtheyhavetoD:isee,hewasslightlyprematurethen,didyouhavegiveyousomehelp?anyproblemsduringNo,itbeganbyitself,althoughIremembersomeofyourfirstpregnancy?theotherwomenintheP:ihadalittlebitofaproblemwithmybloodwardhavingtogetstartedoff/gettinghelp,togelitpressure,itwentabitstarted/high,andiwasin/the/hospitalforafewweeksDoyourememberhowlongthelaborwentonfor?towardstheend.buthewasItwasquitelong,itwasatleast24hours.absolutelyfineanditwasastraightforwarddelivery.Andthedeliveryitself;wasitcaesarean,aforcepsorD:andtheyoungerchild?washeearly,orlateoronwasitnormal?time?Weill,intheendhavetouseforcepstohelpgettheP:hewasactuallyaweeklate,andtheyhadtostartbabyoutbecausehewashimoff/inducelabour/,beginningtogetabittiredaswell.andthentheyneedtheforcepstopullhimout,butDidyouhaveanyproblemsafterthat?sincethenhe'sbeenhewenttothespecialcareunitjustforafewhoursabsolutelyfinebecauseIthinkhewasD:ok,aretheyquitewellnow?alittlebittiredandafterthathisheadleanedtooneP:yes,they'reabsolutelyfine.sidefbraweekor2butthenhewasallright.27PREECLAMPSIA/TOXAEMIAWhatkindoffeedingdidyouuseforthefirstchild?preeclampsiadidyoubreast-feedorD:we'venoticedthatyourbloodpressureisalittlebottle-feedhim?bithighonthisHewasbreast-fedforthefirstsixweeks,butafteradmission,howhaveyoubeenfeeling?thathedidn'tseemstoP:nottoobad,apartfromtheodd/anoccasional/begettingenoughmilkandhealthvisitorsuggestedheadachewetophimupwithD:howoftenhaveyoubeengettingtheseheadachesbottles/formula/.eventuallywejustgraduallychangeP:well,i*vehadthemforthelast2dayshimovertobottleD:anythinglikedizzinessorblurredvision.feeding.IalsohadtoexpressmilkforawhileP:i'vebeengettingsomeflashinglightsinfrontofbecauseafterhetriedthemyeyes,butijustputbottlehewaslazyaboutsuckingatthebreast.thatdowntotiredness.i*vealsonoticedmyringsarereallytightonmy29MISCARRIAGEfingers,andmyfeetaregettingtobequiteswollenHaveyoueverbeenpregnantatallapartfromhavingthese2children?28GENERALQUESTIONSREGARDINGWellJdidhaveamiscarriageinbetweenthem.PASTPREGNANCIESDoyourememberhowmanyweeksonyouWhenyouhadyourfirstchild,doyourememberwere/whatweekyouwerein/,whenyouwhatkindofanestheticsyoumiscarried?hadforthedelivery?thatwasquiteearlyon,abouttenweeks.Imanagedatfirstforalittlewhileusinggasandairandwerethereanyproblemsafterwards,didyou16
17needDandCoranything?cervix_theneckofyourwombtocheckitout.afterYes,1hadaquickDNCafterwards,butthereweren'lthat,wellstretchanyfurtherproblems.itgradually,thenwe'llusesuctiontoclearupwhatisHadyoubeenpregnantatanyothertimeapartfrominthewomb,theonesyoumentioned?finally,we'lljustgivetheinsidewallagentlescrapewell,whenIwasmuchyounger,!didhaveatocheckthatit'sterminateon,anabortion,whenIclear.wasabout19,doyourememberhowmanyweeksonyou31DELIVERYwere/whatweekyouwerein/whenit10deliveryhappened?Iamnotsure,butIthinkitwasabout2month,Ijust3-10-awentintothehospitalwell,lookingatthedatesofyourpregnancyyourandtheydidanoperation,andthatwasthat.babyisreallyquiteoverduenow.itshouldhavebeenhereabout10daysago.andwereallydon'tliketo30DILA(TA)TION&CURETTAGEleavethemmuchlongerthan2weeksovertheduedilatation&curettagedate,sowhatwewilldoisbringyouto/the/hospitaltomorrowandgetthedeliverystarted.thewayweThepatientisgivenageneralanestheticandplacedusuallydothisistobringyouininthemorningandinalithotomyposition.justpop/apply/somegelupbythecervix,andseeiftheperineumandvaginaarewashedwithBetadinethatgetsthingsstartedoff,thatshouldmakethesolutionandthelegsandcervixsofterandeasiertoopenup.Andifyoustillsurroudingareacoveredwithsteriledrapes.haven'tgoneintolaborbyyourself,wecanputadripThepatientisthenexaminedbybimanualpelvicup,thatwillcausetheuterustobegintocontract,andexaminationtodeterminethesowhenyourcervixisopenalittlebit,wecanbreaksizeoftheuterus,thedirectionoftheuterus.andanythewatersaroundthebabyandthatshouldgetthingsadnexalpathology.started.ThecervixisthenvisualizedusingaSimssspeculumandtheanteriorlipof3-10-bthecervixisgraspedwithavulsellum.D:haveyourwatersbrokenyet?/haveyourwaterThecervixisdilatedusingHegardilatorsofbroken?increasingsize.thecavityofP:yes,abouthalfanhourago.uterusisthenevacuatedusuallybysuctionD:areyougettinganytighteningorregularcurettage.inothercircumstancescontractions.itisemptiedusingsimplyspongeforceps.thecavityP:well,i'vebeenfeelingthissortoftightfeelingofuterusisthenacrossthetopofmytummy/stomach.checkedusingacurettetoensurethatit'sentirelyD:howoftenareyourcontractionscoming?empty.P:aboutevery10minutesatthemoment.Theoperationisthencomplete.D:aretheygettinganystrongerorclosertogether?P:they'regraduallygettingalittlebitstronger.theyFirstwewillputyoutosleep,thenwewillexamyourusedtobeabout20minutesapart,andidefinitelywombtoseehowbigitfeelthemcomingonharder.isandwhetheritspositionisnormal,wewillthenD:howlongdotheylastwhentheycome?have/take/alookattheP:justaboutaminuteatthemoment.17
18D:aretheyverypainfulordoyoujustfeelapain,thenwe'lluseacathetertoemptythebladder,tighteningacrossthetummy/stomach?afterthatwe'llgetholdofthebaby'sheadwithsomeP:theyYereallybecomingquitesorenow...forceps,atthenextcontraction,whileyouareD:nowyou*vebeendoingverywell,itwon'tbelongpushingwewillbegivingalittlepull.weshouldn'tbeforeyourbaby'shere,theheadiscomingnow.needtodothisformorethanthreecontractionsthendon'tpush,pantlikeadoguntiltheheademerges.everythingwillbefine.P:ha....D:nowonelastbigpush.32CONTRACEPTIONP:ha...᤺D:congratulations,youhavealovelybabyboy,herecoilcap/diaphragm⚠coitusheis.nowpushonelasttimefor/the/afterbirth.interruptusឋminipillᑺP:ha IUD/intra-uterinedeviceᑁᘤᦻbeforestartingtheprocedure,thepatientshouldbeHaveyouthoughtofwhatsortofexamined,onabdominalexaminationthereshouldbecontraception/contraceptive/you'dliketouse?noheadpalpableabdominally,thecervixshouldbeWell,Iwonderedaboutapill.fullydilatedandthebladdershouldbeemptied.theThat'squiteagoodidea,therearedifferenttypesofpositionofthefetalheadbedeterminedandthepillthatyouneedtothinkaboutandtheyallworkmaternalpelvisfelttobeadequatefordeliverydifferently,there'swhatwecallthemini-pillwhichvaginally.theperineumisthenwasheddownwithanhasasinglehormoneinitbutyoudoneedtobemoreantisepticsolutionandthelegsandsurroundingareascarefulaboutwhenyoutakeitbecauseitonlyhasacoveredwithsteriledrapes.it'sessentialthatthethreehourgapinwhichitissafeandifyoutakeitmotherhaveadequateanalgesiawhetherthisisbyanylaterthanthatthenit'snotworkingreliably,epiduralandaesthesiaorperinealinfiltrationorathecombinedpillontheotherhandhastwotypesofpudendalblock,whentheuterusisnotcontractinghormonesinit,andithasmuchwiderrange,youcanwell,theforcepsareapplied.duringthenextbeupto12hourslateandifllstillworkreliably.contractionthemotherisaskedtoactivelypushHoweversomepeopledofindthattheyhavewhiletractionisappliedontheforcops.theshouldbeproblemswithbothtypesofpills,Forexample,theynomorethanthreemoderatepullsrequiredtodelivedgetheadachesormigrainesorputonweightandthebaby,anepisiotomyisusuallyrequired,anditissomepeoplealsohasproblemswiththeirbloodrecommendedthatitshouldbearightmediolateralpressure,soitisnotalwayssuitable,episitomy.followingdeliveryofthebaby,theanotheroptionistohaveacoil;however,wedon'tplacentaisdeliveredeitherbymaternaleffortornormallyrecommendthistowomanuntilthey*vehadcontrolledcordtraction.thevaginaisthenexaminedatleastonechild,becausesomestudieshaveshownforanyfurthertearstheepisiotomyisrequiredinthatalthoughthecoilitisn*tnecessaryassociatedlayersusualluwithVicryl,whichisasyntheticwithcausinginfections,ifyoudohaveanypelvicabsorbablesuture.hemostasisshouldbeachievedbyinflammatorydiseases,itcanbemadeworse,anditthisandtherectumshouldbecheckedbydigitalcanincreasetheriskofinfertility.thereforeitexaminationtoensurenoneofthesutureshaveusuallyonlygiventowomanafterthey'vehadatreachedtherectalmucosa.leastonechild.thecapordiaphragmhasitsadvantageinthatitwearegoingtohavetogivethebabyalittlehelp,doesn'tinvolveanyhormones,therefore,you'renotbecauseitisgettingalittledistressed,whatwearemucking/messing/aroundwithyourbody'scyclegoingtodoistogiveyousomethingtohelpwiththeanditalsomeansthatitcanbeputinbeforeyou18
19haveyourintercoursenotlikesheathoranythingssoflushes/flashes/,Iwouldwakeupinthemiddleoftheit'sinandoutofthewayandoutofyourmind,nightabsolutelydrenchedwithsweat,mybedclotheshowever,youdohavetohaveitquitecarefullyfittedandnightiewouldbesoakedthrough,theyseemtoandyouneedtobequiteconfidentwithyourownbegettingabitbetter,but,Tmstillawfullytired.bobyinlearninghowtoputitin.ifyouareatallMu,haveyoufeltunwell?embarrassed,itcanbeverydifficult.Notreally.Apartfromtheterriblesweats.ifyouabsolutelycertainthatyou'vefinishedyourHowoftendoyougetthem?familyoryou'renotplaningonhavinganychildren,perhapsonceortwiceanight,it'sreallydisturbingit'spossibletobesterilisedorasitissometimesmysleep.called"haveyoutubestied1'.itnormallyinvolvesjustApartfromlackofsleep,hasiteffectedyourlifeinminoroperation.youarejustinforaday,welookanyotherway?insideyoutummywithatelescopeandcutandtieoffWell,Ihaven'tasmuchenergyandittakesmucheachyourtubestostoptheeggfromreachingthelongerformetogetthroughmywork,Ifelltiredallwomb,anditstopsyoufromgettingpregnant,it'sathetimeand...it'sinterferingwithoursexlifeabitvery,veryreliablemethod,ithasaverylowfailurebecausemyvaginaissodry.rate,butit'smaindrawbackisthatshouldberegardedasbeingabsolutelyirreversible,andonce34HYSTERECTOMYit*sdoneyoureallycan'thaveitchangedback,soyou᤺havetobeverysurethatyoudon'twantanymoreHysterectomyfallopiantubeestrogenprogesteronechildren.hormoneosteoporosisincisionendometriosisfibroidcoitusinterruprus,alsocalledtherhythmmethod,isamalignantovarydroopbiopsypatchgrowthsveryunreliablemethodofcontraception,wherethemanwithdrawsfromthefemalejustbeforeheᦻcomes/ejaculates/reachsorgasm/,however,thereisWeneedtoremoveyourwomb,togiveyouaoftenasmallquantityofspermreleasedevenbeforehysterectomy,we'Hputyoutosleepunderageneralthemancomes,and,therefore,it'sanextremelyanaesthetic,we'lleithermakeacutinyourtummyorunreliablemathod.performtheoperationthroughvagina.Inyourcase,condomsorsheathsarequiteasafereliablemathodunfortunately,we'Hhavetoremovenotonlytheofcontraception,themaindisadvantageisthattheywombbutalsothetubesandovaries.Tmafraidwehavetoputonduringorshortlybeforeintercourse,havetodothistopreventthediseasefromspreading.andthiscan,therefore,interruptthespontaneityofAftertheoperation,youwon'thaveanyperiodsandlovemaking,however,theydohavetheadvantageofsadlyyouwon'tbeabletohaveanychildren,protectingagainstsexuallytransmitteddiseasebecausewehavetoremovetheovariesthereisa(STD).possibilitythatyoumightgethotflushes,andnightsweatsanddrynessofthevagina---allsymptomsof33CLIMACTERICthemenopause,butthisdoesn'talwayshappen.ThisClimacteric.isbecauseyourestrogenandprogesteronehormoneHaveyouhadanyproblemssinceyourlastperiod?levelsdrop.Yourovariesproducethesehormones,ifActually,mylastperiodwasaboutayearsago,Iyoudohaveproblemswecanalwayshelpbygivinghaven'thadoneforaboutayearsnow.youHRT(hormonereplacementtherapy)intheHaveyouhadanybleedingatallsincethen?formofpillsorapatch.However,topreventNo,Ihaven'thadanybleedingatall.osteoporosiswealsorecommendthisHRTtoHaveyouhadanyproblemswiththe"change"?patientswithoutsymptoms,youmayalsofeelabitIusedtohavesomeproblemswiththeseterriblehotlowanddepressedbutusuallyitsoonpasses,andyou19
20mayalsogetabitofaproblemwithyourweight.AHowmanychildrendoyouhave?lotofpeopleseemtoputonweightafteraAreyouandyourhusbandbloodrelatives?hysterectomy.Werethereanyproblemslikebleedingoranillness?Youwillhavetostayinhospitalforabout6daysWasyourpregnancyplanned?wherewecankeepyoucomfortablewithpainkillersDidthebabyarriveattheexpectedtime?necessary,thenyouwillhavetotakeiteasyforaWasthebabybornmormallyordidyouhavetohavewhileandgetplentyofrest.Youcangraduallystartforcepsorasectionoranythinglikethat?doingthingsagain.Ittakesabout6to8weekstoreallygetovertheoperation.After6week,FilwantGoodmorning,Mrssmith,I'mDro'Hare.Iamayoutocomeinforcheck-upjusttoseethatconsultantpediatrician.Tdliketoaskyouforalittleeverythingisok.backgroundinformationaboutJames.Firstofall,ifIfyouhaveanyquestionsregardingthisoperation,youdon'tmind,I'dliketotakeyourightbacktothedon'tbeshyaboutaskingme.beginning.Couldyoutellmeaboutyourpregnancy?Howoldwereyouwhenthebabywasbom?Whatyouhaveisfibroids.ThesearegrowthsintheTwentyseven.womb.theycanbeverylargebutyoursaren'ltooHowmanytimeshaveyoubeenpregnant?bad,that'swhat'scausingyourpainandheavyThree.bleeding,butdon'tworryit'snotcancer.Whatnumberpregnancywasthischild?Youhaveadroopedwomb,whathashappenedisThiswasmythirdpregnancy.thatthemusclesinyourpelvisaren'lholdingitinHowmanychildrendoyouhave?placeanymoreandithasslippeddownintoyourThree,withthisone.vagina.Whataretheagesofyourotherchildren?theproblemiscalledendometriosis,thelininginTwoandthree.yourwomb,that'scalledtheendometrium,hasAreyouandyourhusbandbloodrelatives?startedtogrowoutsidethewombitself.No.I'mafraidyouhaveapelvicinfection,yourovariesWereyouunwell/well/duringyourpregnancy?Wereareinfectedandinflamed,sometimesitcanaffectthethereanyproblemslikebleedingoranillness,ordidfallopiantubesandthewombaswell,butinyouryoutakeanymedication?case,it'sjusttheovariesatthemoment.WithalltheNo,therewerenoproblems.excessivebleedingitlookslikehavearealmenstrualWouldyoumindmeasking,Mrs,Smith,whetherthedisorder.pregnancywasplanned?ThebiopsyshowsthatthereiscanceroftheuterusYes,wehadbeentryingforsixmonths.andpossiblytheovariesareaffected.Didthebabyarriveattheexpectedtime?Well,infact,hecamethreeweeksearly.35NEONATALHISTORYWasthebabybornnormallyordidyouhavetohave᤺forcepsorasectionoranythinglikethat?Caesareansection.Yes,IhadtohavethebabybyCaesareansection.ᦻDoyouknowwhythebabyhadtobedeliveredbypediatrician,section?neonatalhistoryYes,becausethereweresignsthatthebabywasgettingdistressedinthewomb,soIwasadvisedthatHowoldwereyouwhenthebabywasborn?hehadtobedeliveredimmediately.Howmanytimeshaveyoubeenpregnant?Whatnumberpregnancywasthischild?36BABYSCONDITIONATBIRTH20
21Baby'sconditionatbirthlookatJamesandcheckthingout,likehisheartandHowwasthebabyatbirth?Didhehaveanyproblem?chest.WhatI'mdoingnowisI'mjusthavingalookHowwasheinthefirstfewdaysoflife?DidtheatreflexestomakesurethattheyareinplaceIwouldbabystaywithyouordidheneedtogotospecialexpectthemtobe,nowIamgoingtohave/take/acareortothenurseryforanyreason?gentlelookinhismouth/gently/withthiswoodenYes,hewastakentospecialcareunitbecausehewasspatula,nowlookinginhismouthIcansee hatheverysmallandhewasgettingcoldandneededtobehasalittlebitofthrushsoTilgiveyousomethinggivenoxygen.calledNystatinforthat,tohelpitgoaway.CouldWasthebabypremature—preterm,appropriateforyoutellme,MrsSmith,whetheryouhaveanydates.overdue?concernsaboutJames?Hewasthreeweeksearly.Wellyes,doctor,I'mlittlebitconcernedabouthisWhatdidheweigh?cordbecauseIwouldhaveexpectedtohavecomeoffOnlyfivepounds.bynow.Wasthejaundiced?_Yellowwhenhewasborn?Will,infact,Mrs.Smith,thiscantakeaweektotenYes,hehadphototherapyforjaundice.daysbutiftherewereanysignsthattheseparationofDoyouknow,Mrs.Smith,whetherJameshadtothecordisdelayedorifitwasbecominginfectedhaveanyassistancewithhisbreathing?Washeonthenrdjustgiveyousomealcoholswabssothatyoutheventilator,forexample,orwashejustonoxygencancleanaroundthebellybuttonatbathtimeorinhisincubator?whenyouchangehim.Hehadtobeventilated.Didhehadhaveanytransfusions?Hello,MrsSmith,wouldyouliketoundressJames?Yes,healsohadanexchangetransfusion.I'dliketoseehowhisweighthasbeenprogressinginDidhehadanyotherproblemthatyouareawareof,thelastcoupleofweeks....Threehundredsgrams,suchasinfectionsoranyneedforresuscitationwhile/12ounces/that'sfine,isn'tit?Nowriljustexaminehewasinthespecialcareunit?himandhavealookathowthingsaregoing.AreyouNo,Idon'tthinkso,Doctor,buttheyarerecordedinhappywithyourbreast-feeding?How'sthatgoing?hisspecialcarebabynotes.Fine,Ithink,althoughhealwaysseemstobehungryandIwondersometimeswhetherhe'sgotsomepain37NEWBORNCOUNSELLINGinhistummy.᤺Well,it'salwaysworthwhilecheckingwhetherhe'sspatulan."#$%#&'()ᑐ+,-gotanywind/gas/that'sgivinghimdiscomfortinhisNystatinn..ᑴ◭12ᑴ312"45ᢙ◭1&(tummy.Youdon'tneedtogivehimanythingforthis.thrushn.7ḝ9:;<9"=Ḅ(?@ῖB:It'sjustaquestionoflettinghimsituprightalittle□;whileafterafeed.Howoftendoeshehaveadirtyswabsn.DE&Fvt.G)HInappy/diaper/?nappy/diaper/n.JKAboutonceaday,usuallyafterafeed.cotdeathLMNOPᔠRWhatdoesthestoollooklike?Isityelloworgreen?duvetn.vSுᵨVWXW'ᑴᡂḄZ[Doesitsmellstrong?umbilicalcordn.ᾮ]Well,it'sverypalebutitdoesn'tsmelltoomuch.Thatseemsok.CanyoutellaboutJames'sᦻimmunizations?NewborncounsellingYes,he'shadhistriple,doctor.Good,howarethingsgenerally?anyanxietyaboutWhatrdliketodoknow,Mrs.Smith,isjusthaveaJames.?21
22No,notreally,Tmabitworriedabouttakinghimouthisbrain.inthiscoldweatherthere.DoyouknowhowtheyestablishedthathehadhadWell,It'sagoodideatotakinghimoutinthefreshsomebleedinginhisbrain,MrsGreen?air.ButyoumustobviouslydressappropriatelyforYes,hewentforanultrasoundscanofhisbrainthetemperature.whenhewastwodaysoldandthatconfirmedit.Whatwouldyouadvise,doctor,aboutdressinghimDoyouknowifhehadanyinjuriesduringtheatnighttimeforsleep,becauseFvehearddifferentdelivery.viewsonthis.No,therewasnoproblemsthere.Yes,that'squitetrue,Mrs.Smith,thereisquitealotAndalso,doyouknowwhetherhehadanyofevidencetodemonstratethatit'swisenottocongenitalabnormalitiesnoticedafterdelivery?overwrapyourbabyatnighttimeasthere'saclearWell,doctor,thedoctorexplainedtousthatJohnhaddisadvantagefromthiswithrespecttothingslikecotbeenbornwithsomeofthingsthatshouldhavebeendeath.So,whatIwouldadviseisyouneveruseainhistummyupinhischest.duvet/paddedblanket/withanewbaby.It'snotrecommendedforababybecausebabiesarenotableDoyouknowifhehadaninfection?toloseenoughheatiftheyarecoveredwithduvet.Doyouknowifhebecamejaundiced?Doyouknowifhehadanybleedinginhisbrain?38NEWBORNDISEASESDoyouknowifhewentforanultrasoundscanofhisNewborndieasesbrain?DoyouknowifhehadanyinjuriesduringtheMrsbrown,1justhadalookatbrown'shipsduringdelivery?myexamination,IfeelthatweneedbesurethathisDoyouknowifhehadanycongenitalabnormalities?hipisdevelopingnormallyandthere'splentyofroomforthetopofthehiptofitintothepelvicbone.AsI39FEEDINGhavesomedoubtsastowhetherthereismore᤺movementinthehipthenIwouldexpect,1thinkitFarex^_`abḄ45LMcᱏwouldbewiseformetoarrangefbrBraintohaveanBootsef4ghᏉj┝lx-rayofhiships,andalsotoaskacolleaguewhoisanorthopaedicsurgentocomeandhavealookandfeedingseewhetherhefeelsthatweneedtotakeanyactionalongthelinesofdoublinguphisnappiesorCouldIaskyou,Doctor,whatyouradvicewouldbeapplyingasmallsplintuntilthehipstabilises.ifIweretobreast-feedmybaby?HowoftenshouldIdothis?So,Johnhadrespiratoryproblems,somebreathingWhatIwouldrecommendisthatyoufeedonproblemsinthefirstfewdaysoflife.Couldyoutelldemand.Particularlyinthefirstfewdaysoflifeasmeaboutthose?thiswillallowJamestogetyourfeedingpatternWell,weweretoldthathislungswereveryimmatureadjustedtohisneeds.Bygivehimfeeds/byfeedingbecausehewaspreterm,andheneededtohavehelphim/ondemand,he'llgraduallydeveloparegularwithhisbreathingwithamachine.Idoknow,Doctor,feedingrhythem.though,thathehadextraproblemsbecausehehadaninfectionandhealsobecamejaundiced,andatthatDidyoubottle-feedyourbabyordidyoubreast-feed?timethedoctorexplainedtomethattheythoughtheIbreast-feed.mayhaddevelopedjaundicebothbecausehewasAndhowdidthatgo?prematureandalsobecausehehadsomebleedinginIhadtogiveupbreast-feedingbecauseIdidn'thave22
23enoughmilkandIpackeditin/gaveup/afteraboutIshegettinguptocrawl?threeorfourweeks.Ididn'thaveanymilk.ThebabyIshepullinghimselfup?wasnotsatisfiedsoIdecidedputhimonthebottle.Ishetryingtogetontohisknees?HowmanyouncesdoeshetendtotakewithanyoneIsheholdingontofurnituretostandandcruisefeed?/move/around?Fourounces.Whencouldhesitupbyhimself?Howoftendoeshefeed?HowoldwasJameswhenhestartedtowalkingEverythreeorfourhours.completelyonhisown?Howdoeshisfeedinggo?doeshetakealongtimetoWhatdoyouthinkaboutthenoisethatJamesmakesfinishhisbottle?tocommunicatewithyou?Doeshecry?doesheNottoolong,aboutfifteentotwentyminutes.babble?doeshehaveanyoohahhorgaganoises?Doesheusethemtoattractyourattention?Howlongdoesthebabyspendintheincubator?Doeshegetholdof/grab/grasp/thingswithhisIdon'treallyknow,Doctor.handsyet?Whenwasyourbabyallowedtogohome?Doeshereachwithbothhandsoronlyone?Whenhewasthreeweeksold.Doeshepassthingsbetweenhishands?Washetube-fedintheincubatororwereyouabletoCanhefeedinghimselfwithaspoonorwithhisbreast-feedhim?hands?Hewastube-fedatfirst,butthenhewasabletoputCanhegetholdof/grab/grasp/adrinkingcup?himonthebreast.41INFANTCOMPLAINTSHowlongwereyouabletobreast-feedhim?InfantcomplaintsOnlyforthreeweeks,Iamafraid.Igather,MrsSmith,thatyouhavesomeconcernsAtwhatstagedidyouweanthebaby?aboutJames,couldyoutellmewhattheyareandWhenhethreemonths.whentheystarted?WhatsortofthingsdidyouofferhimwhenyouWell,afterafeedhim,doctor,heseemstobeinstartedweanhim?discomfortanddrawshiskneesuptohistummyandIstartedhimonFarexwithsomeegg,andsomecries.Sometimehedoesitbetweenhisbottles.Bootsbabyfoodintins/cans/jars/.Howlongafterhe'sfinishedhisfeed,doeshedothis?Hasthebabybeenreceivinganymedication,anyWell,ittendstobeabouttwentyminutesafterhe'svitamindroporiron?finishedhisbottles,buthecanalsoberestlessandYes,hehasvitamindrop.criesthroughoutthenight.Doyouthinkhe'sgainingweightallright?40PSYCHOMOTORDEVELOPMENTYes.PsychomotordevelopmentWell,havingalookatJameshere,Ifeelquitehappythatthere*snothingabnormallygoingoninhisDoyouhaveanyconcernsaboutthewayJamesseestummyandIthinkwhat'sprobablyhappeningisthatoranyconcernsabouthiseyes?Doesheturntotheheisexperiencingcolic.Althoughit'sveryawkwardlight?doeshefellowyourface?DoeshefellowaforyouandJames,it'snotgoingtodohimanytermlight?harm.AndnowIwouldadvisethatyoutryveryWhatabouthishearing?Isheawareofnoise?Doessamplemeasuressuchasadropofphenolgripeheturnhisheadwhenhehearsanoise?Doeshewater.recognizeyourvoice?Howishegettingonwithmovingabout?Isheable42FEBRILECONDITIONrollover?23
24᤺materialoranyblood?HashehadanyupsetofhisCalpolᡫnopbowels?syrupn.qrstqrᑺYes,it'softenwhite,butthere'snoblood.Febrileadj.uvḄnwḄCouldyoutellmehowoftenheisopeninghisbowels/hasbowelmovement/?whetherthestoolᦻlooksanydifferentfromnormal?FebrileconditionIt'syellowishandquitehard.Doctor,FmveryworriedaboutJamesbecauseheHowdoyouthinkJamesisbehaving?DoyoufeelseemstohaveahightemperatureandIcan'tgetittohe'sbehavingnormally?settle.No,Idon't,doctor,heseemsveryirritableandupsetDoyouknowhowhighhistemperatureis?andcriesalot.Noexactly.Well,whatIproposetodoistoexaminehistummyWhatmeasureshaveyoutakentotryandgethiswhilehe'stakingafeed.Soifyoupop/put/himontemperaturedown?yourlapandjustputhimtothebreast...Well,WhileWell,doctor,Ihavetriedanumberofthings.ItookI'mfeelinghistummy,1canfeelalittlelumphisclothesoff,andgivehimsomeCalpolandIalsounderneathmyfingersandwhatthatindicatestometrysponginghimwithtepidwater.isthathe'sgotsomeovergrowthofthemuscleattheWell,thatisquitetherightapproach.ifyoucouldexitofthestomach,andthatisblockingthematerialslipJames'sclothesoffriljusthaveaweelookandlikehismilkdrainingfromhisstomach,soIthinkseeifwecanestablishthecauseofhistemperature....thatit*slikelythatwhatweneedtodoisasmallWell,thatdidn'ttakealongtoestablish.Tmafraidoperationtocutthroughthemuscleandrelaxit.James'sgottonsillitis,whichiscertainlyagoodenoughcauseforhistemperature,sowhatI'lldois44DIARRH(O)EAFilgivingyouanantibioticsyrup,givehimoneDiarrheateaspoonfulthreetimesadayandthatshouldsettleit,Goodmorning,Doctor,I'mconcernedaboutmyson.I'dlikeyougivehimthefullcoursesocan-yonHe'snoweightmonthsoldandhe'sbeenunwell,givinghimteaspoonfulthreetimesadayuntilthehe'shadatemperatureandhealsohaddiarrhea.bottleisfinished.Couldyoutellmealittlebitmoreaboutthediarrhea?Howoftenisitoccurringintheday,andwhatdoes43PYLORICSTENOSISthestoollooklike?PyloricstenosisItwaswatery?CouldyoutellmewhenJameswasborn?Couldyouseeanybitsoffoodinit?/didithaveanyAboutamonthandahalfago.foodpiecesobservableinit?/Sohe'ssixweeksnow.SowhendidyourconcernNo.abouthimstart?wasthereanymucusorbloodoranythingunusualWell,Fvebeenconcernedabouthimfortwodayswiththediarrhea?nowbecauseheseemstobevomitingaftereveryYes,therewasbothmucusandblood.feed.Howmuchhasthebabybeendrinking?CouldyoudescribewhatthevomitingislikeMrsI'mafraidnotvery/too/much.Smith,Forexample,doesitclearyourlapandlandWell,JamesseemstobequitedryandIthinkhe'sonthefloor?probablynotbeenkeepingenoughfluidsin.SowhatWell,hisvomitingisverystrong,doctor,hethrowswe'Hneedtodoistosetupanintravenousinfusionthevomitrightacrosstheroom.togetthefluidsdirectlyintohiscirculationtobypassAnd,whatisinthevomit?Doyoueverseeanygreentheproblemthathe'shavingbylosingfluidsthrough24
25hisdiarrheaandhisvomiting.catchinghisbreath/.IsitthefirsttimethatJameshasfounditdifficulttoGoodmorning,Mrssmith,wouldyouliketositgetitbreath?downandtellmewhatyourconcernsareaboutNo,thishashappenedthreetimesbefore.James?Howfrequentlydoyouthinkitoccurs?Well,he'svomitedseveraltimesthismorningandWell,asIsaid,ithappenedaboutthreetimes.he'salsohaddiarrhea,andIthinkhe'salsoHaveyounoticedanyrelationshiptothetimeoftheexpressingsometummyacheandhe'sverylethargicyear?Isitmorelikelytohappeninthespring,fortired.instance,ratherthaninthewinter?Hashehadatemperature?No,ifanything,it'sslightlymorelikelytohappeninYes,Ithinkhehas.winter.Haveyounoticedanybloodinhisstool?Andhaveyounoticedanythingelsethatbringsiton?No,Ihaven't,thestoolisjustloose.Yes,Ihave,italwaysseemstobeassociatedwithaHowishemanagingtodrink?cold.Well,he'smanagingquitewell,he'squitekeentoHaveyounoticedanythingelse,suchas,doesitstartdrink,but,unfortunately,he'snotabletokeepitwhenhe'srunningaboutorwhenhe'sbeenindownandit'sallbeingvomitedbackup.contactwithanimalsoranythinglikethat?Well,let'shavealookhimthen.Couldyoupop/take/No,Ihaven't,althoughImustadmithe*snotveryhisclothsoffandI'llhave/take/alittlelookfirstallatathleticandhedoescomplainsometimeswhenhe'shistummy...Wellit'sallveryreassuring,Ican'trunningaboutalot.Itmakeshimcoughandfindanythingwronglookingathistummyandheparticularlyincoldweather.seemstobekeepingplentyoffluidsin,soyouareHashehadanytreatmentforthis?beingsuccessfulwithyourencouraginghimtodrink.Yes,hehashadsometreatmenteverynowandthen,Ithinkwhat'sprobablyhappenedishe'sgotanhehashadaninhalerwhichhashelpedalittlebit.infectiousdiarrheaandwhatwouldbeasensibleWhataboutthepresentepisode?Whattreatmenthasthingtodowouldbetocollectasampleofhisstoolhehadforthis?andsentitoffforbacteriologyanalysis,we'llhaveWell,he'snothadanythingforthisonebecauseItheresultsinthreeorfourdays5times.washopingitwouldjustsettleonitsown.Well,WhatshouldIdointhemeantime,doctor?Andwiththepresentepisode,howdifficulthasitWell,theimportantthingistomakesurethathehasbeentogetitbreath?Hashebeenabletotalktoyousufficientfluids.So,aslongashe'shappytodrink,allright?thenhewon'tgetintotoomuchdifficulty,andthenIfsbeensodifficulttocatchhisbreaththatheoncehe'sfeelingalittlebitbetter,youcouldstartcouldn'tspeakclearlytome.introducingagentlediet.Hashelookedblueorpale?No,notthatIremember.45ASTHMA(Obstructivebronchitis)Andhowlongdidthelast?AsthmaEdsayitlastedaroundfiveminutes.ItwasveryCouldyoutellme,Mrssmith,whenJamesstartedscary.coughing?Hasthisbeendifficultythat'smadehimlosetimeWell,itstartedaweekagoandit'sparticularlybadatfromschool?night,hekeepsthewholefamilyup.Hehasn'tbeentoschoolforthreedaysthisweeks.Doyouthinkhe'shavinganyproblemwithchoking?Well,heseemstobeexperiencingquitealotof46ACCIDENTStroublegettinghisairinandgettinghisbreath/25
26Accident,Wheredidyoufindhim?Well,Mrssmith,couldyoutellmewhathappened?Inhisgrandma'sbedroom.Well,TmafraidthatJamesfollowedhisdaduptheDidhisgrandmahaveanymedication?Haveyoustepladderandfelloff.noticedanyofitmissing?Howlongagowasthat?Yes,wehave,itlooksasiftherearesomeredpillsAgoodhalfanhourago.missingfromoneofherbottles.DoyouknowwhatkindofheighthemighthaveAnddoyouknowwhatkindofmedicinehisfallenfrom?grandmatook?Abouttwometers/sixfeet/.Well,it'scertainlysomethingtohelpstrengthenherWasheknockedout?heart.Yes,Ithinkhewasknockedout,notentirely,maybeWell,Ithinkthesafestthingtodowouldbetotryjustforacoupleofminutes.andwashoutJoe'stummy/havehisstomachWasthereanythingelseunusuallyabouthim?didhepumped/sothatwecangettheremainingtabletsout,lookpaleorlimp?beforetheyareabsorbedintohissystem.Yes,helookedverypale.Didhehaveanyjerkingofhislimbs,washesick?47MENINGITISNo.MeningitisDidheseemtobelikehimselfwhenhecameround/Doctor,IamworriedaboutJamesbecausehehasarecovered/(ordidheseemdisorientedorunwell)highfeverandhe'svomitedalot(he'sbeenvomiting)washeallrightordisoriented?ᦻxᫀsinceyesterday.He'sveryrestlessandhe'sbeenHeseemedveryconfusedwhenhecamearound.cryingallthetime.HaveyounoticedanybleedingfromhisnoseorearsCouldyoutellmealittlebitmoreaboutthevomiting?oranybruisingoccurring?Yes,he'svomitedfivetimes,andwhileheisNo.vomiting,heholdshisheadasifit'shurtinghimand...Well,Ithinkwhatweneedtodoistogetanx-rayIthinkhe'sprobablygotaverybadheadache.ofhisskullandinviewofthefactthathehasn'tbeenWell,MrsSmith,IthinkthatIneedtoestablishtowellsincehefellofftheladder,andthathehadawhetherornotJameshasgotmeningitis,andIperiodwhenheloseconsciousness,Ithinkitwouldsuggestthisbecauseofhishistoryoftemperatureandbewiseforustoadmithimovernightjusttokeepvomitingandalsobecausehe'sfindingithimunderobservation.uncomfortablewhenItrytoflexhisneck.Nowit'squitestraightforwardtoestablishwhetherhe'sgotCanyoutellmehowtheburnhappened?meningitis,andwe'Hdothiswithalumbarpuncture.Well,IthinkwhathappenedwashereachedoutforaIt'sveryquicklyundertakenanditshouldn'tbetoocupofcoffeethatIwascarrying?upsettingforhim.ItwilltellusveryquicklywhetherHowlongagowasthat?whatwe'redealingwithismeningitis.Andifitis,Halfanhourago.thanwe'llbeabletostartappropriateantibioticWhatactiondidyoutakeonceyou'drealisedthistherapystraightaway.happen?Well,IstrippedhisclothesoffandIrancoldwater48FEBRILECONVULSIONSontotheburntarea.FebrileconvulsionsHadhebeenunwellbeforethis?Well,Doctor,Tmreallynotsurewhathashappened,Whichpartofhisbodywasinvolvedinthejerking?whenIwentouttotheshopsandwhenIcamebackIWasithiswholebodyoronlyoneside?foundJoelyingthereverypaleandclearlyunwell.Didhiscolorchange?26
27Didheseemtohaveanydifficulty(withhis)inhisbody,soitmustbetepid/lukewarm/waterthatbreathing?youspongehimdownwith.Howlongdoyouthinktheepisodelasted?Didhewetorsoilhimself?49HENOCH-SCHONLEINPURPURADidhehaveacoldandatemperature?Henoch-schnleninpurpuraDoesanyoneelseinyourfamilyhaveanythingCouldyoutellmewhat'sbeenworryingyou,Mark?similar?Well,doctor,Tvedevelopedthesefunnyrashesonmyarmsandmylegs,itjustcameonsuddenlyWell,Mrssmith,couldyoutellmewhat'shappenedyesterday.toJames?Isthereanythingelseaboutthem?AretheyitchyorWell,halfanhouragohesuddenlywentrigidanduncomfortableorsore?blueandstartedjerking.No,theyaren'tsore,buttheyseemtobegettingHadhebeenunwellbeforethis?/hashebeensickworseandworseandtheyalsoseemtobegettingbeforethis?bigger.Yes,hehadhadabadcoldandhespikedaHaveyounoticedanythingelse?temperature/hadahighfever/justbeforetheepisode.Yes,Ihave,whenIgotothetoilet,IthinkI'vgotWhichpartofhisbodywasinvolvedinthejerking?somepinkinmywee/pee/.Wasithiswholebodyoronlyoneside?Andhaveyouhadatummyache?Hiswholebody.Onlyalittlebit.Didhiscolorchange?Wasthereanybloodinyoupoo(poo-poo,doo-doo)?Hewentgrey/gray.No.Didheseemtohaveanydifficultywithhisbreathing?Wasthereanyswellingofyourwrist,elbowsorYes,hewasn'tbreathing.ankles?Howlongdoyouthinktheepisodelasted?No.Around3minutes.Well,WhatI'mgoingtodoisI'mgoingtolistentoDidhewetorsoilhimself?yourbreathing,so,couldyoutakeadeepbreathforNo.me?Right,thatisfine.YoucanjustbreathenormallyDoesanyoneelseinthefamilyhaveanythingsimilar?now.nowFmgoingtolistentoyouheart,justlieYes.IknowwhenIwasalittlegirlIdidhavesomedown.Tiljusthavealookatyourtummy.NowwhatfebrilefitswhenIhadtonsillitis.wealsoneedtodoishavealittlelookatyoupee,soWhatIwouldsuggest,Mrs,smithasensiblecouldyouputalittlebitintothispothere?approach,istotryandkeepJamestemperaturedownintheeventoffurtherfevers,Inordertoseeifwe50BEDWETTINGcanpreventhimhavinganotherfitswithhisfever,so,Bedwettingavoidoverdressinghim,particularly,asyouhaveaSo,MrsSmith,couldyoutellwhatyourconcernsare?temptationtopileclothesonhimwhenhehasaWell,Jamesis9yearsoldnow,andhe'sstillwettingtemperature.Becausehemaylookcoldandthebed.trembling,butdon'toverdresshim.Infact,ifCanyoutellmewhetherhe'salwayswetthebedoranything,takehisclothesoffdownhisnappy/diaper.whetherhehadaperiodwhenhewasdryandthenheYoucanspongehimwithatepidwaterandyoucanstartedwettingagain?alsogivehimsomeParacetamol.Whateveryoudo,Well,Doctor,he'swetthebednearlyfromthewordyoumustnotputhimincoldwater,orinacoldbathgo/fromtheverybeginning.becauseallthatwoulddoisincreasethetemperatureAndwhataboutduringthedaytimes?Doeshehaveanyproblemswettingduringthedaytime?27
28No,he'sfinethen.No,1don'tthinkit'sanydarkerand1haven'tnoticedIsiteverynightordoeshesometimeshaveperiodsanybloodinit.whenhe'sdry?Doyoudrinkalotofwater?No,itiseverynightNo,notreally.Andwhatkindofmeasureshaveyoutakenyourselftoseeifyoucanimproveupit.52ADVANCEDSTAGEOFBPHWell,we'vedonetheusualthingswe'vemadehimAdvancedstageofthebenignprostatehyperplasiagetupduringthenight,werestrictedtheamountthathedrinksafterteatime/intheevening,aftersupper/.So,Iunderstandthatyouareherebecauseyou'veHasyourdoctorgivenyouanythingforit?hadtroublewithyourwaterworks.No,we'venevertriedanything.Yes,mywaterworksarenotasgoodastheyusedtobe,IamgettingupanawfullotandIamrunningto51BENIGNPROSTATEHYPERPLASIAthetoiletallthetime.Urology.Doyouhavemuchinthewayofurgency?ThatisBenignprostatehyperplasiawhenyouneedtogotothetoiletcanyouholdonSoyouhaveproblemswithyouruntilyougelthere?waterworks/urination,urinarytract?Yes,verytime1gotothetoiletIneedtogetthereYes.quitequicklyAnddoyouhavetogomoreoftenthanusual?Doyouevernotgettothetoiletontime?doesiteverYes.leakordribblebeforeyoureachthetoilet.Howoftendoyouactuallygoduringtheday?Thathappenedtometwice,doctor.Aboutfifteen-twentytimesonsomedays.Well,Whenyougotothetoilet,doesittakesomeWhataboutduringthenight?timetobeginordoyoubeginquitequickly?IhavetogetupatleastthreeorfourtimeseachnightItusuallystartsquitequickly,doctor.SometimeitWhenyoudopasswater,doyouhavedifficultiesstartsbeforeIgetthere.starting?Whenyoupasswater,doesitcomeawaywithgoodSometimes.force,isthestreamgood?Doyouhaveanydifficultiesstopping?WhenyouNo,itisnotasgoodasitusedtobe,itisnotasgoodthinkyouhavestopped,doyouhavetogoabitmore?aswhenIwasyounger,Itjustdribbles,Doctor.Yes,yes,that'sitexactly.Doesitstopinstartwhenyou'repassingwater?Afteryouhavestoppedurinating,doafewextraYes,itstopsandstartsoritsprayswhenIgototoilet,dropscontinue?itisnotagoodstreamNo.Whenyoustop,doesitdribbleonattheend?DoesitWhat'sthestreamlike?Isitthesameasitusedtobe?continuetoleakafteryoupasswater?No,ItseemstobejustatricklenowadaysYes,Ialwayswetmypants,doctor,IalwaysleaksDoyouthinkyouarepassingmoreorlessthanyouintomypants.useddo?DoesthishappenimmediatelyafterordoesithappenFmnotsure,doctor.aftersayfive-tenminutes?DoyouhaveanystingingorburningwhenyouIthappensafewminutesafterwards.urinate?Doyoufeelyouemptyyourbladderfully,orafteraYes,Sometimes.shorttimedoyoufeelyouneedtopasswateragain?HaveyounoticedanydifferenceinthecoloroftheYes,whenIgetupinthemorning,Ipasswaterandurine?IsitanydarkerorhaveyouevernoticedanythenIneedtogohalfanhourlatertopasswaterbloodinit?again.28
29Howmuchdoyoupass?DoyoupassalotofwaterNotreally.orjustalittle?Areyouupmuchatnighttopasswater?Alittle.NormallyonceatnightifIhaveadrinkbeforeIgoHowfrequentlyareyoupassingwaterduringthedaytobed,Butotherwisenotparticularlyfrequently.andhowfrequentlyareyoupassingwateratnight?I'mgoingtoexamineyourabdomenanddoarectalIhavetopasswatereveryhournightandday.examination.Sopleasegetuponthebed.NowPmIsitworseduringthenightorworseduringtheday?justgoingtopassafingerintoyourbackpassagetoItisbadduringbothnightandday.feelyourprostategland...isthatuncomfortableatall?doesithurt?...Nowwe'llmassagetheprostateand53CHRONICINTERMITTENTPROSTATITISifthereisanyfluiddischargedfromyoupeniswe'llchronicintermittentprostatitiscollectitandsenditofftothelabforaninvestigationYourdoctorhasaskedmetohaveawordwithyoutoseeifthereisanyinfectioninit.WhatI'mgoingbecausehebelievesthatyouhavehadtroublewithtodoisswabtheurethrawhichistheliningoftheyourprostate.Hethinksyouhavehadsomeprostaticinsideofthepenis.Thiswillbealittleuncomfortableinfection.Doyoufeelyouhavehadanytroublewithbutwouldn'tlastverylong.yourprostate?Yes,doctor.Ihavealotofpain.Everyfewmonths154PROSTATECTOMYhaveanotherboutofseverediscomfort,itfeelslikeaProstatectomylotofpressureandburningsensationjustabovemyInoldermanitisquitecommonfortheprostatetogroin.enlargeandcausethesymptomsyou'vebeenDoyouhaveanyproblemswithyoururinating?experiencing.Torelievethesesymptoms,itmaybeWhal'stheflowlike?necessarytoremovetheprostatebuttherearesomeIt'sgoodbutsometimeswhenIhavetheseboutsitisdrugswhichmayhelp.Beforedoinganythingwequiteslow.needtodosometestsonyourwaterworks/urinaryWhenyoufeelyouneedtopasswatercanyoutract/.Unfortunately,Idon'tthinkthedrugswillhelppostponegoingtothetoilet,ordoyoureallyneedtoinyourcasesoweHlhavetooperate.goquitequickly?Beforeyouroperation,IwouldliketoexplainwhatNormally,doctor,Tmallright,butagainifIhaveanhappenswhenyourprostateglandisremoved,you'llinfectionIneedtogettherequitequicklyandI'mhaveafewtestsbeforeyouroperation,likebloodandgoingtothetoiletquitealotatthattime.urinetests,hearttracing,achestx-rayandsometimesWhenyoustarttopasswater,isthestreamanIVP-intravenouspyelogram,whichmeanswe'llcontinuousordoesitstopandstart?injectsomecontrastingdyeintoyourveinwhichwillIt'salwayscontinuous,Doctor.passthroughthekidneysandthenwe'lltakesomeAreyouabletostoppassingwaterquitewell,ordoesx-raysofyourkidneys.Youwillspeaktoanitdribbleon?anesthetistwhowilldecideonyourtypeofItdribblesalittle,butnotverymuch,Doctor.anesthesia-ageneral-whenyouwouldbeWhenyoupasswater,doyoufeelyouemptyyourcompletelyasleeporanepiduralwhichonlynumbsbladderfully?thelowerpartofyourbody.Yes,Idon'thaveanytroublewiththatunlessIhaveTherearetwowaysofremovingtheprostate.Oneisaninfection,whenIamrunningbackandforthtothebyoperatingafterinsertingatelescopethroughthetoiletallthetime,andIonlypassalittleamountofpenisorbymakingacutinthelowerabdomen.Filurineeachtime.decidewhichmethodtouseafterI'veexaminedyou.Howaboutthewater,doesitsmellorisitAftertheoperationyoururinewouldbedrainedbyadiscolouredatall?tubecalledanin-dwellingcatheter.Youmayhave29
30somebloodinthetube,yourbladderwouldbeinfection,myurineissmelly,itsmellsfoul.washedwithwater.You'llalsohaveatubeinyourIsitcloudyatthattime?armcalledanIVwhichmaysupplyyouwithsalineYesit's(quiteofcloudy.)orblood.Howisyourhealthotherwise,apartfromthis?doIt'srecommendedthatyoustartdrinkinglargeyouhaveanytroublewithdiabetes,heartdisease,quantitiesaftertheoperation,youcanhavetea,bloodpressure?coffee,squashorwaterbutfizzydrinksarenotNo.recommended.ThiswillspeedupyourrecoveryandAreyouonanyothermedication?washawaythebloodinthecatheter.I'mtakingaspirinformyarthritis.ThebladdertubewillberemovedtwotofivedaysHasyourdoctorgivenyouanyantibioticsforthis?aftertheoperation,youshouldcontinuetodrinkasYes,hegivesmesometablets/pills/wheneverIgetmuchaspossibleandpasswatereverytwoorthereaninfection,butinthemeantime,inbetweentimes,hours,dependingonyourrecovery,youareusuallyI'mnotonanytabletsforit.allowedhomeafteraboutfivedays.DrinkalotNow,inthefirstinstance,whatTdliketodoistoliquidsathomeandwe'llgiveyoustoolsoftenertoexamineyou,examineyourabdomenandthenavoidconstipation,ifyouhaveanyproblems,callafterwardswe'Horganizesometests,Tdlikeyoutoyourdoctor.getundressedandputagownonsothatI'mabletoYoursexlifewillchangealittle.Youcanhaveseeyourabdomen,wouldyoupleasegetupontheintercourseafewweeksaftertheoperation,butyoutableandI'llcomeroundandexamineyou....That'swillnotemitanysemenfromyourpenisatsexualfine.Youcangetdown,Now,aboutthetests.Filclimax.Yoursemenwillflowintoyourbladderandsendsomeofyoururineofftobeexaminedintheyoururinemaybecloudyafterintercourse.Youarelaboratorytoseeifthere'sanyinfectionpresent.Weunlikelytoproduceanyfurtherchildrenbutshouldwouldadviseyouinthemeantimetodrinkplentyofnotrelyonthisassafecontraception.fluidsandcarryon/continue/takinganyantibioticsyourowndoctorprescribedfbryou.We'dliketo55CYSTITISorganizeroutinex-rayandanultrasoundscantoCystitisassessrenaltractfurther.AnultrasoundscanisYourdoctoraskedmetohaveawordwithyousimplescan,anditdoesn'tinvolvedanyradiation,itregardingtheurinarysymptomsyou'vebeenhaving.involvesyouattendingthex-raydepartmentforaWhatkindofsymptomshaveyouhad?fewhourandtheyscanoveryourtummywithaOh,Doctor,IhavetopasswaterallthetimeandI'mprobewhichallowsthemtovisualizethekidneysandrunningbackandforthtothetoilet,andit'sburnsthebladder,it'snotapainfulorunpleasantprocedure.andstingseverytime.Oncewehaveallthetests,wemaycallyouintoHowoftendoesthehappen?Doesthishappenallthehaveaninspectionoftheinsideofyourbladder,wetime,orisitanintermittentthing?callitacystoscopy.Ihavegooddaysandhavebaddays,sometimeswhenIgetabadinfectionitcanfloorme/last/fora56CYSTOSCOPYweeks,butatothertimesinbetweenitneverquiteCystoscopyfeelsrightbutit's,youknow,IcanlivewithitwhenMr,abbot,we'lldoaflexiblecystoscopy,faraIdon'thaveaboutofinfectionflexiblecystoscopymbringyouinto/the/hospital,Haveyounoticedanybloodordiscolorationinyourandwe'llpasssomelocalanestheticjellydownurine?throughthepeniswhichwillanesthetizetheentranceYes,Ipassedbloodononeoccasion,butnormallyItothebladderandthenwe'Hpassaveryfine,don'tpassanyblood.SometimeswhenIhaveanflexibletubeintoyourbladderthatwillallowusto30
31seetheliningoftheurethraandliningofthebladder.It'sasharppainthatcomesandgoesinwaves.It'sItalsoallowesustoexaminethesizeoftheprostate.veryseverewhenitcomeson.DoesitmakeyoufeelsickornauseatedwhenyouWhyareyouaskingforacystoscopy?havethepain?Becausewewanttohavealookinsidethebladder,Yes,Ifeelsick.Iwassickonce.we'llgetyouintoahospital,andunderalocalHowseverewasthepain?Howwouldyoudescribeanestheticwe'llanesthetizetheentrancetothethepain?Wasitoneoftheworstpainsthatyou'vebladderandhavealookinsideyourbladder,thisishad?notaveryuncomfortableprocedure,thatsimplyYes,it'saveryseverepain.involvesyoubeinginhospitalforafewhours.Doyouhaveanyassociatedchangesinyoururine,suchasdiscolorationorgritinyoururine?Ifwefeelweneedtocallyoubackforacystoscopy,Yes,Ihavenoticedachangeinthecolor,andmywe'llprobablydothatunderageneralanesthetic.doctorsaysthatwhenheteststheurinetherewaswe'Hbringyouintothehospitalforaday.we'lltakesomebloodinit,butIdidn'tnoticethat,Icouldn'tyoutothetheatre,popyouoff/putyou/tosleepforseeanybloodinmywater.nomorethanafewminutes,thanwe'HpassasmallWhatI'dlikeyoutodoistosituponthebed,firstoftelescopeintothebladderthroughtheurethraandallifyoucouldtakeoffyourshirtandloosenyourinspecttheliningofthebladder.Atthattime,wetrousersandliedown,please?mayalsoneedtotakesomebiopsiesbutyoushouldLieonmyback?beallowedhomelaterthatsameday.Ifyoulieonyourback,Tilexamineyourabdomenfirstofall,andthenI'llexamineyourgenitalia,and57RENALSTONEafterthatrilaskyoutoturnoverontoyourleft-handRenalstonesideandI'llexamineprostatethroughthebackYourdoctoraskedmetohaveadiscussionwithyoupassage,firstofall,Iamgoingtohaveageneralfeelconcerningthesymptomsyou'vebeenhaving,yourofyourabdomenandafterthatI'llexamineyoutodoctorthinksperhapsthatyouhavesometroubleseeifIcanfeelyourkidneys,yourliverandwithstonesinyourkidney.Whendidyoufirstnoticespleen......I'dliketoexamineyourgenitalia.Thatthesymptoms?mightbealittleuncomfortablebuthopefullyFvehadthemonandoffforaboutthreemonths,butwouldn'tbetoopainfulforyou...wasititwasonlylastweekthatIhadsuchasevereboutofuncomfortable?....thatfeelsfine,Ican'tfeelpainthatitmademetogotomydoctorimmediately.anythingunusualinyourabdomen,andexternalHegaveaninjectionforthepainthat'smadethingsgenitaliafeelnormal.Thereisnoabnormality....andsettledownsomewhatsincethen.ButIstillhavegotnowrdlikeyoutoturnoveronyourleft-handthisnaggingdiscomfortthat'soccasionallyquitebadside...canyouholdyourrightkneeuptowardsyouronmyrightsidechestandFilexaminethebackpassage.....ifyouHaveyouhadanytroubleinthepastwithkidneycouldtryandrelaxit'llmakeitslightlylessstonesoranyhistoryofkidneydiseasesatall?uncomfortableforyou.TilputsomecoldjellyonmyNo,Iwasfineuntilthelastfewmonths.finger...Canyoufeelthat?....IsthereanypainorWhereexactlyisthepainthatyouget?tendernessthere?Igetitintherightsideofmyback.It'sjustabituncomfortable,doctor.Doesthepaingoanywhereelse?NowyoucangetupandgetdressedandcomebackYes,itradiatedowntomygroinontherightandinaboutaquarterofanhours.sometimestomytesticles.Whattypeofpainisit?58INFERTILITYEXAMINATION31
32Infertilityexaminationbringingyouinasaninpatientjusttostayforoneday,andthenunderageneralanesthetic,we'lltakeaYourdoctortellsmethatyou'vebeentryingtohavesmallbiopsyofthetesticletolookatundertheafamilyforthelastfouryearsnow.andsofarmicroscope.thistellsushowwellitisfunctioning,you'vebeenunsuccessful.Tdlikeyoutospendafewyou'llbeallowedhomethesameday.momentsansweringthisquestionnaire.FiljustgoIt'snotapainfulprocedureasyouareasleeponthethroughthequestionswithyouquickly.tablewhentheprocedureisdone.Howoftendoyouhavesexualintercourse?59EXAMINATIONOFTHEEARHowlonghaveyoubeenmarried?EarnoseandthroatDoyoulivetogether?ExaminationofearHaveyouanyhistoryofinfections?Letmeexamineyourear,nowI'mlookingfbranyHaveyoueverbeeninthearmy?ulcersorotherabnormalitiesofyourear.PmHaveyoueverhadamedicalinvestigation?strokingyourearwithmythumbinfronttodetectHaveyoueverhadanyoperationsonyourexternalanyscarring.Pmnowlookingbehindyoureartoseegenitalia,onthescrotum,anyhernia,anyifyouhaveanyscarsthere.circumcisionorvasectomy?NowletmepullthispartofyourearoutsothatIcanHaveyouhadanyinfectionsinthewaterworks?putthespeculumintolookinsidewithmyHaveyouhadanysexuallytransmitteddiseases?light,.....verygood.TmgoingtopuffalittlebitofHaveyoueverhadanychildrenbyanyotherpartners?airwiththisballoonintoyourear...verygood.NowHaveyoueverbeeninvestigatedanywhereelseforaFmgoingtohavealookwiththemagnifyingsimilarproblem?otoscope,andifweneedtolaterwecanusetheoperatingmicroscopetoseeyoureardruminmoreWhenyouhavecompletedit,comethroughintothedetail.office....NowFdliketoexaminetheexternalgenitalia.IfyouI'mgoingtocalloutsomenumbers,repeatthepopup/sit/onthebed,thenrilexamineyournumbersIsay,Tmgoingtoputmyhandacrossyourabdomenandgroinregions.Theexaminationmayeyessoyoucan'treadmylips,andmyfingerinyourcertainlybeabituncomfortablebutitshouldn'tbeotherearandwiggleitslightlysothatwe'reonlytoopainful.testingthisear.NowI'mtwofeetawayfromyouatNowrdliketogetabloodsampleforhormonemyarm'slength.Tmgoingtocalloutsomenumbers,leverswhichwillbesentofftothelab,andwe'dlikerepeatthenumbersIsay:Eighty,sixty,forty-two,togetasemensampleinordertoanalyseitunderthesixteen,sixty,eighteen,eighty,twelve,whatdidIsay?microscopeinthelab.whatI'dliketodoistotakeDidyouhearanything?Tellmewhenyoucannothesetwopotsaway,andafterthreedaysofnotlongerhearit,nowrilturnyouaroundandrildohavinganyintercourses,putasampleintothispotbythesamewiththeotherear,VWcoveryoureyesmasturbatinenotusingacondom,becausetheagain,thistimeFilblockingtheotherear,repeatthecondomeffectsspermcount,andthenbringitintonumbersIsayagain.thislabfreshonthesamemorningofcollection,weusuallyhavetwosamples,oneweekapartand60DEAFNESSthereafterweHlseeyoubackintheclinicinacoupleDeafnessofweeks'timetoseeyouwiththeresults.Ifyouhavealowspermcount,wearrangeforbloodteststoDoctor,Tmhavingproblemswithmyhearing.checkthehormonecirculatinginyourbody,Isee,well,I'dliketotestyourhearingnow.Whichsometimeswemayhavetodoatesticularbiopsybyisyourbetterhearingear?Whichisyourworse32
33hearingear?I'veworkedinthesteelworksforthirtyyearnow.Idon'tknow,I'mallrightonetoone,butinacrowdWheneverIgethomeatnight,there5saringinginI'museless.Ican'thearthedoorbell,Ican'thearmyearsandIhavethetelevisiononveryloud.Ipeoplespeakonthephone.EveryonecomplainsthatthinkIamgoingdeaf.Ihavethetelevisionontooloud.IfIgooutintoaLittleJohnhasn'tbeenwell,hehasbeenill,hehascrowd.I'vehadit.Ihearallthenoisebehindme.hadaheadache.He'sbeenterrible,hehasbeencryinghalfthenightandnowhisearstartedrunning,Mybabyissixmonthsnow,doctor,buthedoesn'tandhe'sbeenfeelingsick.seemtohearme.EverysinceIhadscarletfeverwhenIwasseven,myDoeshesmile?Doesheknowyou?earshavebeenrunningonandoff.IthappensseveralIfheseesme,yes,butheneverseemstohearmeandtimeduringthewinter,Ijustfeelmyearpouring/Iheisnottalkingatall.canfeelmyeardraining/,anditgetworse,sometimeDoesdeafnessruninyourfamily?issmellsterrible.Well,Ithinkmygrategrandmawasdeaf,butI'mnotsure.Wasitanormalbirth?62TINNITUSNo,hewasborntenweeksearlyandwenttoaTinnitusspecialcarebabyunit.Hehadmeningitisthen,buthelookedasifhewasnormal.Myearsarealwaysringingdayandnight,Ican'tIthinkwe'dbetterdosomespecialhearingteststosleep.checkoutyourbaby'shearingWhichisyourbadear?Myrightearhurts.61PATIENTS*COMPLAINTSDoesisrunaswell?Patient'scomplaintsYes.Ihadabadheadcoldlastweek,andsincethenIHasyourhearinggotworselately?can'thear,myearsfeelcloggedup.LastnightIwasIt'sbeenbadwhileisbeenrunning.ill,Ihadafeverandhadaterribleearache,justDoyouhearnoisesinyourears?terrible.Itwentonandon.ItthrobbedandsuddenlyYes,Tvegotrunninginmyrightear.myearburst.What,sitlike?Isithigh-pitchedorisitlow?MyearalwaysfeelsblockedupandIcan'tgettheIt'sahigh-pitchedwhistling,likemachinery.blockageout/itclearedout/.Iputcottonbuds/balls/Doyouhaveitallthetimeordoesitcomeandgo?inandpulledthisstuffout.butitonlyseemstogetDoesitthrobwithyourpulse?worse.ItitchesterriblyandsometimesIthinkI'mIhaveitmostofthetime,doctor.goingdeafDoyougotdizzyatall?Duringrugbyyesterday,thispropfellonmeandhitYes.thesideofmyhead.IthasbeenbleedingsincebutWhenyou,redizzy,doyoumeaneverythinggoesnowit'sstoppedandIthinkFvegoneabitdeaf.roundandroundincirclesordoyoujustfeelwobblyIwasservingatabarinapub,whensomeonetookaonyourfeet?disliketomeandhitmeonmyear.TvebeendeafonEverythingspinsroundandround.thatsideeversince.Doesitmakeyoufeelsickorareyousick?/doesitIwasinacaraccidentlastweek,andmyheadhitthemakeyoufeelnauseousordoyouactuallythrowup?sideofthecarandsincethenIcan'thearinthisear.IFvebeensickforthelasttwodays,butnowIjustwasinAngelhospitalovernightandx-rayedmyskull.feelsick.I'mnotactuallyvomiting./I'mnotactuallyTheydon'tthinkI'vefracturedit.vomiting,butIfeelnauseous./33
34Doyouhaveaheadachewiththis?putyourheadonthepillowthere,turnslightawayYes,it'sthere.formme,that'sgood.FmbringinthismicroscopeinI'dliketotestyourhearingwiththistuningfork,THyourearandfocusingitonyourear.Tmputtingastrikethistuningfork,andputitonyourforhead.speculuminyourear.Nowyou'llfeelsometicklingWheredoyouhearit?Doyouhearitinthemiddleoranditching,Tmusingalittlehooktogetthewaxout.onlyinoneofyourears.Hereitcomes,we'vedone.It'sintherightear.Verygood.NowIstrikeitagain,andholditnextto64OTITISEXTERNAyourleftear,doyouhearit?OtitisexternaYes.Myearisitchingallthetime,doctor.Iputitbehindyourear.Isitlouderofsofter?Doyoukeeppokingitwithyourfinger?Louderbehind.IknowIshouldn't,butIdo,andIscratcheditandVerygood.Nowtheotherear,I'llstrikethetuningmadeitworse.forkandholdituptoyourear.Doyouhearthat?Haveyouhadanyeardropsfromyourdoctor?Yes.No.Louderorsofter?Letmelakealook.Louder.A.Right.Aha,you'vegotwhatwecallanouterearinfection,youhaveamixtureofwaxandskininyourearcanal,63WAXPLUGINTHEEXTERNALEARbecauseyou'vebeenscratchingandbecauseyou'veWaxpluginyourexternalearaninfectioninyourear,it'sitching.TilcleanitoutMyearfeelsallblockedup,doctor,andFvebeenwithsuction/sucker/andgiveyousomeeardrops.deafsinceyesterdaywhenIwashavingabath.Willmyhearinggetbetter,doctor?Doesithurt?Yes,itwill,it'snottheeardrum,thehearingpartofNo.yourear,justtheouterearDoesitrun/drain?BNo.Ijustcan'thear.You'vegotfuruncleorotitisexterna,you'vegotanRight,sitdown,turnaround,letmelookintoyourouterearinfection,you'vegotboils,thatiswhyit'sear...aha,it'sfullofquitehardwax.Doyougetalotsotenderlikeaboilanywhereelseonyourbody,weofwax?aregoingtoputadressingintodrawit,comebackIsupposeIdo....onFriday,we'lltakeitouttoseeifthey'vecometoaThiswaxistoohardforustogotoutnow.Youhavehead.toputsomealmondoiloroliveoilfromthesupermarketinyourear.Warmitslightlybeforeyoucometoaheadᾱ{ᡂ|putitintoyourearandcomebacknextweek.We'lltakethewaxout.65OTITISMEDIAWell,thewaxlooksquitesoft,sowellsyringeit.otitismediaNowleanslightlyover,putthisapronaroundyousoFvebeenhavingtroublewithmyears,Ihaveayoudon'tgotwet,andFilputitkidneybowl/basin/terribleearache.Ican'tseemtohearwellatallandunderyourear.Tilfillupthisbigsyringe,righttoFvehadatemperatureonandoffforaweek.thetop.TilputanozzleintotheupperpartofyourYou'vegotanearinfection,thereispusbehindyourear,thewateriswarm,soyoushouldn'tfeeldizzy,eardrum,we'dliketoletitout.Whatwewilldoisherewego.putsomecreaminyourears,ananaesthetic,letitLiedownonthiscoughhere,underthemicroscope,34
35workforhalfanhour,andthenwe'llmakeanickinsame.youreardrumandletthepusout.we'vecauterizedyournosehere,we'vemadeascabwhereitwasbleeding,itwillbeweakforafewdays,66FOREIGNBODYINTHENOSEsodon'tblowyournosehard,pulsomevaselineinForeignbodyinthenoseyournoseovertheareaforthenextweekwhileitDoctor,wethinkourlittlegirl'sgotabeadupherheals.nostril,it'smissingformynecklaceandhernosehasbeenrunningsince.Wethinkwecanseeit.Whichsideisbleedingmore?It'syourright,is'nlit?Right,nurse,wouldyoucomehere?...sitonIsmuchofthebloodgoingdownintoyourmouth?mummy'slap.Lieback,let'sputthissheetroundNo,itisn't.you,welldone.Thenurseisgoingtoholdyournose,That'sgood.Doyoueverhavetroublewithyourthat'slovely.NowI'vegotthislittlemagiclight,Tmbloodpressure?goingtolookinyournose.Welldone,Ihaven'tNo.lookedupyournosebefore.Nowwait,PmputtingDoyoubruiseeasily?Yes,youdo.Yourskin'sthislittlehookdownit.Ohh,nowit'sout.Herewegettingthinnerasyougetolder,isn'tit?Now,we'llare.Nowpromisenevertodoitagain.beasquickaswecan,sithereonthischair,welldone.Let'sputthisapronaroundyourneck,breathe67NOSEBLEEDSthroughyourmouth.There.we'HbeshiningalightNosebleedupyournose,holdingitopenwithaspeculum.We'llIhavealotofnosebleeds,doctor.beusingsomesucktion.TmgoingtoputsomesprayWhenyoublowyournosetoohard?onyournose,itdoesn'ttasteverygood...breatheWell,yes.Sometimesitjusthappensanyway.throughyourmouthwhilewedoit,verygood.TilbeHaveyoueverbrokenyournose?pullingoutthisbloodclot,welldone.Ican'tseeNo.whereit'sbleedingfrom,TilIputthebandageinDoyoubruiseeasily?yournostrilstostopitandyouneedtostaywithusNo.overnight.Bearwithus,TmputtingthistapeinyourHaveyoueverhadtroublewithyourbloodpressure?nose,it'sribbongauzewithsomeBIPPonit.KeepNot,asfarasIknow.going,theworstisovernow.afewmorelayersofit,Letmelookupyournoses,tiltyourheadback.It*sverygood.Hasitstoppednow?good.weMlputthistherightsidethatbleedsmore,isn'tit?littlebolsteroveryournosetokeepthedressingin.Yes.stayinhospitalovernight,andstayinyourbedalltheYou'vegotsomeweakbloodvesselshere,theyaretimebecauseifyoustrainorcoughorliftthingsorveryprominentinwhatwecall“little'sarea”,Ithinkmovearound,youmaystartthebleedingagain.that'swhereyou'rebleedingfrom.Tdliketocauterize/cauterize/those.NowI'mgoingtospray68SINUSITISthisareawithsomelocalanesthetic,openyourSinusitismouthandbreathethroughyourmouthwhileIdoit,Aitdoesn'ttasteverygood,nowwaitacoupleofFvegotthepatientsittingonachairupright,moments.Hasthetastegone?Good,Letmeseeyourbreathingthroughhismouth,TmusingtheBulTsnoseagain.Tmputtingthespeculumin,I'mgoingtoeyelump,shinningitonhead-mirrorfocusonhistouchthisareawiththestick,wecancauterizeit.nose.We'regoingtoperformatest(proof)punctureAhh,you*rebleedingslightlynowfromthatweakoftheantrumusingaTilly-lichtwitztrocarandpoint,THholdthestickonitforaminute,goodit'scannula.We'vepreparedthenosewithalocalstopped,now,thereareafewotherareas.Tildotheanaestheticusingtwentyfivepercentcocainepaste35
36onthecotton-woolonasilvercocainizingwire.Ifthedrops.patientshouldfaint,thesilverwillbendastheyAnybenefit?collapse,whichiswhyweusesilverwire.I'mnotreallysure.ThelocalanesthetichasbeenthereforsometenSitupinthischair,Tilturnonthelighttolookupminutestoshrinkthemucosaintheinferiormeatusyournose.Tmholdingyournostrilopenwiththisandalsoforlocalanesthesia.He'snowgotsomespeculum.NowFmlookingupwithmylight.Areanesthesiaintheregionoftheantero-superioryoutenderhereonyourcheekandaroundyoureye?alveolarnerve.Il'snumbovertheincisorandcanineYes.teethonthatside,sowe'llremovethecocainizingYou'vegotanastyleft-sidedsinusinfection.Nowitwire.Now,holdingthenostrilopenwiththehasn'tgotbetterjustwiththeantibiotics.TheX-rayspeculuminmylefthand,I'mpassingthetrocarandshowshereyou'refullofpusonthatside.We'dcannulaundertheinferiormeatus.Themeatus'sbetterdrainit.Nowwedon'tneedtoputyoutosleepattachmentissomewhatcurvedsoI'llpassitbackforthis,we'lldoitwithyouawake.TilputthisuntilIfeelresistanceandIpullbackslightly,turntheanestheticonthiscottonwoolonthissilverwire,putpointtowardsthetragusoftheipsilateralearandI'mitinyournose.Nowwaitthereafewminutes...Areenteringtheantrumwithaslightboringaction.Tveyourteethgoingnumb?putmyindexfingerouttostopmefrompenetratingYes,theyare,it'sodd.toofar.ThenIentertheantrum,nowFiladvanceRight,thenitshould'veworked.NowI'Htakethisslightlyfurther,pullbackthetrocaruntilthetipofout.Youshouldshutyoureyesforthis.Tmholdingthecannulaisinthemiddleoftheantrum.First,yournoseopenwithmyspeculumagain,andI'mwe'llaspiratepususinganordinary10mlsyringe.passingthisupyournose.It'sabitlikesyringingupNowwe'vetakenaspecimenofpus,andwe'llsendtheinsideofyourcheek.Hereweare.Tmgoingtoitformicroscopycultureandsensitivity.Nowwe'vepushnow.wait,right,nowwe'rein.welldone,that'sgoingtoirrigatetheantrumusingtheHigginson'stheworstpartover,nowwe'llsuckthisout.Ahsee,syringe.Weputsomewarmwaterinabasin.Theyou'vegotpus.Verygood.Fmalmostfinished.NowHigginson'ssyringeisarubbersyringewithacentralI'mgoingtosyringethroughit.I'vegotabowlofbladder,andpipingatbothendswhichwe'llattachwaterhereandaHigginson'ssyringe.Right.NowthroughanIver___lockconnectortothecannula,you?11feelasthoughit'sbeingscratched.Openyourandwe'llplacetheotherendinthewater.Thenmouthwide.Breathethroughyourmouth.Yoirllfeelpumpingthebladder,thesinusisirrigated.Wearewatergoinginandoutthroughyournose.Justletitusingsuctionfromthehospitalsupplytosuckoutdropoutandwe'llsuckitout.Keepthroughyourexcessfluidasitreturns.mouth,justletthewaterrunoutofyournose.Welldone,it'scomingbackclearnow.wecanstop.BDoctor,Ihadthisbadheadcold,it'sgone,butnow69DEVIATEDNASALSEPTUMFvegotthispaininmyleftsideofmycheekandDeviatednasalseptumaroundmyeyes.It'sthrobbingbehindmyeyes.Doctor,Icanneverbreatheoutofmyleftnostril.Doyourteethhurt?Haveyoueverbrokenyournose?Yes,theydo,nowthatyoumentionit.ThepaingoesYes,lastyear.roundtomyearaswell,it'sterrible.IfIleanforwardHaveyouhadanybadcoldsorhightemperatureitthrobs.I'vehadsomemuck(-colloquial)/drainage/lately?comingout.No.Haveyouhadanymedicine?Areyouotherwisewell?Yes,fvehadsomeVibramycin,andsomenoseYes.36
37Doyougethayfeverinthesummer?Wedoitunderageneralanesthetic.It*sdonethroughNo.yournostril,thereisnocutsonyourface.Whafsyourjob?Noblackeyes.Iworkinanoffice.Notforthisoperation.WhenyouwakeupfromtheIsitverydusty?anesthetic,you'llprobablyhaveabandageupbothNo,notreally.nostrilsovernightso,yousee,you'llhavetobreatheDoyousneezeorhavewaterystuffcomingoutofthroughyourmouththatnight.Wouldyouliketheyournosesorgetanitchynoses?operation?Notreally.Willitwork?Doyoureyesrun?Yes,wecanseethatwecanmakethingsalotbetterNo.thantheyarenow.Doyougetanypusoutofyournoses?Thatdoesn'tsoundtoobad.Tilhaveitdone,please.No,notreally.Ijustcan'tbreathethroughitandIsnore.70PHARYNX-LARYNXEXAMINATIONDoyoutendtobreathethroughyourmouthallthePharynxandlarynxexaminationtime?I'mgoingtoexamineyourmouth,openyourmouthYes,Ido.Anddoctor,inthemorningmymouth'swideforme.letmeputthesetongueterriblydry.depressor/blades/underyourlipstolookfromsidetoIthinkthat'sbecauseyou'vebeenmouth-breathingside,stickyourtongueout,liftituptotheroofofallnightandyou'vedriedyourmouthout.Canyouyourmouth...downagain...toyourright....toyoursmell?left.Fmgoingtolookatyourvocalcords.CanyouWell,Ican'tsmellatthemoment.takeoutanyfalseteethyouhave.Situpstraight,leanDoesyournosebleedatall?veryslightforwards,I'dliketolootdeepintoyourSometimes,itbleedsonthisblockedside,especiallythroatwiththismirror.Fvewarmeditwithaburner,whenIblowmynosehard.youcanseeit'snothot,Icantouchit,anditdoesn,tNow,sitdown.I'dliketolookupyournoses.Sniffhurt.Openyourmouthwide,stickyourtongueout,forme,sniffontheotherside.NowI'llshinethisI'mgoingputaswabrounditandholdit.Breathelightupyournostrilandholdyournostrilopenwithsteadilythroughyourmouth,I'mpassingthismirrorthisspeculum,andnowtheotherside,verygood.tothebackofyourmouthandnowsay"ee”.Well,Mr.Williams,itistheleftsideofyournoseBthat'sblocked.EverydaywhenIwakeup,mymouth'sdryandIYes,sinceIbrokeitlastyear.can'ttalk.IhavetohaveafewdrinksorsomethingYou'vegotadeviatenasalseptum,thispartofyourtogetmouthworking.Asthedaysgoeson,myvoicenoseiscartilage,andinsteadofbeingstraightit'stiresaswellandIgethoarse.twistedandthetwistisblockingyouontheleftside.rdliketolookdownyourvoicebox/larynx/withPmpleasedtosaywecanfixitforyou.Wecanputthismirror,openyourmouthwide.Thatislovely,itrightwith/correctitby/anoperationtostraightenputyourtongueout.Letmeholditwithaswab.Tveupyournose,astherearenomedicinesortabletswarmedthemirrorslightlyontheBunsenburner.It'sreallythatwillhelp.nothot,youcanseethat,BreathethroughyourIsitabigoperation?mouth,situpstraight,leaningveryslightlyforwardNo,nottoobig,it'squitecommon.Ifyouagree,lovely.Letmeputthistothebackofyourmouth,we'llbringyouintothehospitalthedaybeforethekeepyourtonguedown,that'ssuperandsayoperation,youcanusuallygohomethedayafter“hay”….youroperation,orpossiblytheseconddayafterthat.You'vegotlaryngitis,yourvocalcords,yourvoice37
38box/larynx/,theyareallsore.Doyousmoke?Here,overononeside.Yes.Right,nowletmehavealookatyou.Sitdown,openDoyouuseyourvoicealot,doyoushoutalot?yourmouth.Headslightlyforward.LetmeputthisYes,Iamaschoolteacher.tonguedepressoronyourtongue.TmshiningthisYoumustrestyourvoiceasmuchasyoucan.Youlightin.hah,thereisafishboneinyourtonsil.Nowreallyshouldstopsmoking.Takecarewithhotandholdsteady,breathethroughyourmouth,andFilputspicyfoodorcolddrinks.thisforcepsin,holdit....welldone.That'sout.That'sout.Trytoswallow,doyoufeelbetternow?71CANCEROFTHELARYNXCancerofthelarynx73TRACHEOSTOMYTUBECHANGEFvebeenhoarseforaboutamonth.TracheotomytubechangeDoyousmoke?Weneedtochangeyourtracheotomytube.We'veYes.gotthenewonereadyherewithanintroducer.Let'sHowmuch?untiethesetapesaroundyourneckandbringthemTwentyaday?round.That'sgood,wehavethesuctionrunninginDoesthatmeanfortyaday?caseweneedit.WehavetosuckyourtracheotomyIfsmight.beforewetakeoldtubeoutincaseyouhavealotofDoyoudrinkmuch?mucus.Webendthesuctiontube(aswe)putitin,Well,IlikeaglassofwhiskeywhenIgotobedatit'llonlysuckaswepullitout.Nowtakeadeepnight.breathforme,andwe'llpullthetubeout.Right,weDoesanythingbotheryou?areputtinganewtubein.it'sin.let'stakeouttheWell,hotfoodhurtsmythroat.cannula,verygood,youmaybreathe.Let'sputtheseDoyouhaveanydifficultswallowing?tapesinandtiethembackagain.Sometimes.Doyougetanypainsinyourears?74GOODANDBADNEWSYes,whenIswallowmyearhurts.GoodandbadnewsNow,I'mgoingtolookatyourlarynx,yourvoiceGoodmorning,MrGorden,sitdown,isyourvoicebox....You'vegotsometroublewithyoularynx,Tmbetter?notquitesurewhatitisbutyouhavebeenrather/Clearsthroat/Yes,MrMarleod,notprefect,butatharshonyourvoice,itmightbesomethingnasty.WeleastIcantalk.Doyouhavemyresults?reallywillneedtogetyouintothehospital,putyouYes,Ido.I'mpleasedtosaythere'snosignoftosleeptolookatitwhileyouareasleep.Welltakecancer,but...abiopsyandseewhatitis.ThenseeifweneedtodoOh,ThankGod,nosignofcancer,nosignatall?anything.Yes,that'sright,butlistenforamoment.You'vedoneyourvoicealotofdamagewithsmoking,andalotofoveruseatwork.Icould'tbesureitwasn't72FOREIGNBODYINTHEPHARYNXcanceruntilwehadtheresults.InthefutureyouForeignbodyinthepharynxreallymusttrytostopsmoking,aslongasyoukeepIwaseatingthishaddockyesterday,andIamsureIsmokingyoucangetmoretroublewithyourvoice,feltsomethingstickthere.IthinkFilnevereatfishandonedayitcouldturnnasty.again.Oh,yes,doctor,I'mtrying.Fvecutdownalot,butCanyoueatanddrink?youknow,it'snoteasy.Ican,butwheneverIdoFilfeelitthere.Well,doyourbest.Todayit'sgoodnewsforyou.Whereisit?Pointitouttome.ButIdowantustoseeyouagaininamonth,and38
39keepaneyeonyouforthepresent.Doesitfeelnormal?No.Goodmorning,MrDuncan.How'sisyourvoice?Inwhatwaydoesitnotfeelnormal?Muchthesame.Perhapsalittlebetter.Itfeelsnumbcomparewithmynextfinger.Now,MrDuncan.Pleaselistencarefully.We'vegotWhendidyoulasthaveanantitetanusinjection?theresultofyourbiopsy.AndFmafraidwewillIhaven'thadany.needtogiveyoumoretreatmentofyourvoice.TheBreport'scomebacksayingthatsomeofthesampleDoctor,Tveinjuredmyhand.IthinkImayhavelooksnasty.Thereissomecancerthere,notalot,butbrokenabone.some.Tellme,MrsJohns,howdidyouinjureyourhand?Soitiscancer,doctor?Islippedonsomeice,andfellandlandedwithmyYes,MrDuncan,butwe'vecaughtitearlyandtherehandoutinfrontofme.istreatment,anddoesitworkwell.IfyouaregoingCanIseeyourhand?Showmehowwellyoucantogetacanceranywhere,yourlarynxisoneofthemoveyourfingers?bestplacestogetit,wecangiveyoutreatments,andIt'spainfulwhenIbendmymiddlefinger.manypeopledoverywell.Yourhandismoreswollenandtenderinthepalm...IIsittakingmylarynxout,doctor?thinkyoumayhavebrokenabone.IlikeyoutohaveNotinyourcase.We'llgetyouseenbythex-rayanx-ray.doctorsnextweek.Thetreatmentisx-rays.CFvecutoutthecigarettes,doctor.Doctor,Tveapainful,swollenrightknee.That'sverygood.You'recertainlydoingyourpart.Howdiditoccur?OurpartistogetthetreatmentstartedassoonasItwistedmykneeplayingfootballyesterday,Iwaspossible.Tilarrangeyourappointmentattheunabletocontinuetoplayingthegameandsinceradiotherapyclinic.Wouldyoulikemetospeaktothenmykneehasbecomemoreswollenandpainful.yourwife?Canyoumovetheknee?No,I'lltellher.WhenItrytomoveit'spainful,andI'munabletofullystraightentheknee.D75INJURIESComein,MissMillerandsitdown.What'stheInjuriesmatter?ADoctor,IsprainedmyanklegettingoffthebusDoctor,Fvecutmyhand.yesterday,andnowIfinditverydifficulttowalk.Letmesee.Wherehaveyoucutyourhand,MrSmith?Letmeseeit.Canyoumoveyourankle?MoveitupJusthere.anddown.Iwanttocheckifyouhavetornligaments.Howdidithappen?Oh,doctor,that'ssore.IwasusingasawtocutsomewoodandthesawFmsorry.Tilbemoregentle.MissMiller,thereisslippedandslicedmyfinger.swellingandtendernessovertheoutsideoftheankle.Hastherebeenalotofbleeding?Ithinkyouareright,you'vesprainedyourankle.IYes,thebloodwasspurtingoutatfirstandithasrecommendthatyouwearthebandageandhavesoakedthroughmyhandkerchief.somephysiotherapy.Canyoubendyourfinger?Yes.76DIAGNOSISCanyoufeelmetouchingthetipofyourfinger?DiagnosisJust/barely/justbarely/Hereyoucanseeafracturethroughthethirdbone39
40whichiscalledthemetacarpal,youcanseethattheboneisbentandinorderforyoubeabletouseyour77TREATMENThandnormally.1thinkweoughttogiveyouanDamien,I'veputtheplaster/cast/ontokeepyouranaesthetictoputyoutosleepinordertostraightenboneintherightposition.It'sveryimportantthatthebone.Weshouldbeabletoholditstraightwithayoudon'tgettheplasterwet,becausethenitwillplaster,butil'spossiblewemightneedtoputwiresbecomesoftandthebonemaymove.Tdalsolikeinthebonetoholditinplace.Sothatyoudon'tfeelyoutocomebacktohospitalstraightawayifyouranypain,we'llneedtoanesthetizeyourhand.Thisfinggertipsfeeltinglyornumborifyourfingersgocanbedonebyinjectiontomakeeitheryourhandorpaleorblue.Thiswouldsuggestthattheplasterisyourwholearmgonumbbutifyoupreferyoucouldtootightandwe'dneedtosplitittorelievethegoofftosleepundergeneralanesthetic.pressure.Inordertoavoidswellingwithintheplaster,IrecommendthatyoukeepyourhandupsothattheThekneeisveryswollenandit'spossibletheremayswellingcandrainaway.You'llneedtobeinthebesomebleedingwithinthejoint,youaretenderplasterforsixweeksaltogether,butwe'llneedtogetovertheinsideofthekneeandareunabletofullysomex-raysdonebeforethen,tomakesurethebonesstraightenthejoint.Tmsureyouhavetornthehaven'tmoved.cartilageovertheinsideoftheknee.You'llrequireDamien,I'mpleasedtosaythatyourfacturehasanoperation.Iadviseanarthroscopyunderageneralhealedinaverygoodpositionandnowwecanlakeanesthetic.Thisistheinsertionofanarthroscopeintothecastoff,I'mgoingtouseaspecialsortofsawtothekneethroughaverysmallopening,weareabletocutthroughthecast.Itmakesaloudnoisebutit'sseetheinsideofyourkneeonatelevisionscreenandverysafe.Itvibrates,sowillnotcutyourskinevenIamcertainwe'Hfindyouhavetornthecartilage.Ifthoughitcutsthroughtheplaster.thatisthecase,atthesametime,we'llgoaheadandremovethetompartofthecartilage.Thiswillrelieve78SCOLIOSISthepainandswellinginyourkneeandallowyoutoScoliosisreturntofootballinthefewweek'stime.Doctor,Tvenoticedthatmydaughter'sspinehasbecomecrooked.MrsSmith,Tdliketoexamineyourshoulder.PleaseWhendidyoufirstnoticethis,MrsBlack?showmehowfaryoucanmoveit,canyouraiseyourItwasduringthesummerwhenmydaughterwasarmoveryourhead?Farwardsandnowtothesides.wearingat-shirt.InoticedthattherightsideofherCanyoutouchthebackofyourhead?Nowcanyoubackappearedveryprominent.touchthemiddleofyourbackwithyourhand?Andsinceyoufirstsawthat,hastherebeenanyThat'sgood.changeintheshapeofyourdaughter'sback?Howwellcanyoumoveyourelbow?CanyoubentitNo,notreally,althoughitmayhavebecomeslightlyupandstraightit?Nowstopmefrombendingitandmorecurvedoverthelastfewmonths.stopmefromstraightenit.Now,I'dliketoexamineHowisMary'shealth?yourwrist.Cockyourwristupandnowbentitdown.Sheisusuallyaveryfitgirl.ShehassufferedfromCanyoutwistit,asthoughyouwereturningakey,asthmainthepast,butdoesn'ttakeanymedicinefirstonewayandthenother,now,Iliketoexamineregularly.yourhand,pleasesqueezemyfingers.CanIexamineIsthereanyoneelseinyourfamilywhosufferedeachfingerinturn?Touchyourthumbwitheachoffromcurvatureofthespine?yourfingers.NowpinchyourindexfingerandyourYes,mybrother,that'sMary'suncle,wasquitethumbtogetherandstopmefromseparatingthem.severelydisabledbycurvatureofthespinewhenhewasinhisteens.40
41Isee,soyou'reobviouslyconcernedthatthesameCongenitaldislocationofthehipthingmayhappentoyourdaughter.Hello.MrsSmith.mynameisdoctorJones.FmoneYes,doctor,that'sright.oftheorthopaedicsurgeonsatthehospital.AndI'dWhatrdliketodonowistoexamineMaryifthat'sliketoexaminelittleJohn'ships.Thisisaroutineallrightwithyou.procedurewhichweperformonallnewbornbabies.Yes,pleasegoahead.SituationoneMary,whatI'dliketodofirstis(to)examineyouFmafraid,MrsSmith,thatoneoftheJohn'shipsstandingup.Please,couldyoutakeyourclothesoffclicks.Thisisquiteacommonfindingandreallyforme...thankyou,wouldyoupleasestandascausesprobleminthelongterm,itdoesn'tneedanystraightaspossible...That'sgood,nowwalkacrossspecialtreatmentatthemoment,butIwouldliketotheroom....That'sfine.Nowstopandturnaroundreexaminejohninfourweeks.andcomebacktowardsme....Ok,comeandstandinfrontofmeagain,nowstandwithyourbacktome.I'mafraid,MrsSmith,thatoneofJohn'shipscamenowleanforwardasfarasyoucan.Nowleanback.outofjointwhenIexaminedthem.ThiswillneedNowstandstraightagain,nowleanovertotheright,treatmentnow,butbecauseithasbeendetectedsoandnowleantotheleft.WhatTdliketodonowissoonitshouldn'tcauseanyproblemsinthelongterm.examineyourlegs.WouldyoulieonthecouchforIrecommendthatJohnweardoublenappies/diapers/mepleaseMary....Ineedtogetsomex-raysofyourtostartwithandIwishtoreexaminehishipsinfourspine.Thesewouldbetakenwithyoustanding,fromweeks.thebackandfromtheside,andFilseeyouagainafterthey'vebeendone.MrsSmith,TmafraidthatoneofJones'shipsisoutofjointandhisrightlegisshorterthantheleft.IMarry,Fmpleasedtosaythatyourscoliosis,whichwouldliketogetanx-ray.iscurvatureofyourspine,isnotverysevereandtheMrs,Smith,I'msorrytosaythex-rayconfirmstreatmentIrecommendisphysiotherapy.Ithinkit'sJones'shipisoutofjoint.IfItisleftinthispositionbestforyoutohaveexercisestoimproveyourthenthehipwillnotdevelopproperlybutifwetreatposturewhichwillincludesomeinthehydrotherapyitatthisearlystagethenhestandseverychanceofpool.developingnormally.Thetreatment,firstofall,istowearthisplasterdevicecalledaPavlikharness,butifEmma,youhavescoliosis,I'mpleasedtosaythatthisisunsuccessfulthenJonesmayneedanoperationyouwon'tneedanoperationtoputthisright.Mrstoputthishipbackintojoint.Thomas,scoliosisiscurvatureofthespine,nooneisquitesurewhatcausesitbutwecanbecertainthata8()DISLOCATIONOFTHEHIPASALATEcurveoftheamountthatEmmahaswillnotprogressCOMPLICATIONenoughtorequireanoperation.However,inordertoDislocationofthehipasalatecomplicationstopitdeteriorating,IrecommendthatEmmaisputinaplasticbracewhichsheshouldweardayandHello,MrsWallis.MynameisdoctorTrelawney.nightforthenextfewmonths.We'llneedtokeepaComeinandsitdown.IhavealetterherefromyourcloseeyeonEmma'sspinetomakesurethatthedoctorbutI'dliketoaskyouafewquestions,aswell.curvedoesn'tgetworse.Howoldareyou?I'mthirty-fiveyearsold.79CONGENITALDISLOCATIONOFTHEHIPWhat'syouroccupation?I'mashopassistant/storeclerk/.41
42Whatproblemsareyouhavingatthemoment?straightenitagain.Nowmoveitacrosstome.AndMyrighthipissoreandI'mhavingdifficultynowtotheotherside,nowturnitinandturnitout.walking.That'sgood,Ineedanx-rayofbothhipsandpelvis.Howlonghaveyouhadtheseproblems?I'vehadthemformanyyears.MrsWallis,Ihavetheresultsofyourx-rays.TheseHowdidtheybegin?Wasitsuddenorgradual?showyouhavesevereosteoarthritisofyoulefthip.I'vereallyhadtheproblemsforaslongIcanThisisduetoacongenitaldislocationofthehipremember,butihey'vebeengettinggraduallyworsewhichyou'vehadsincebirth.Ithinkthebestovermanyyears.treatmentforyouwouldbeanoperationtoreplaceDoyourememberanaccidentatthestartofyouryourlefthip.trouble?Tellme,doctor,isthatamajoroperation?No,theproblemsseemedtodevelopfornogoodYes,itisundoubtedly.Butyouarehavingsomuchreason.troubleIdonotthinkthereisanyotheralternative.WhatareyoupreventedfromdoingbyyoursorehipI'mveryworriedaboutthis,doctor.Whatdoestheatthemoment?operationinvolve?Fmabletodoverylittle,IstruggletowalkjustafewItisamajoroperationwhichwouldrequireyoutobehundredmeters.inhospitalforabouttwoweeks.You'llcomeintoWhereisyourpain?hospitaladayortwodaybeforesurgerysothatweIt'smainlymylefthip,butmyrightkneeisalsocanexamineyouandcheckthatyouarefitforanslightlysore.anaesthetic.TheoperationitselfinvolvesquitealongWhendoyougetthepaint?cutontheoutsideofyourthighandthenthewornIhavethepainmostofthetime,butitgetsworsepartofyouhipwillbecutawayandreplacedwithatowardstheendoftheday,especiallyifI'vebeenonmetalandplasticjoint.Thisshouldmakeyoumoremyfeetallday.comfortable,anyyourhiplessstiff.Butofcourse,asDoyoulimp?withanyoperation,thereisasmallriskofYes,Ilimpverybadly.complications.Doyouneedtouseastickorcrutchestogetaround?Whatarethosecomplications,doctor?Yes,IhaveawalkingstickwhichIholdinmyleftThemaincomplicationaretheseriousoneswhichhand.canoccurduringanyanaesthetic.ThereisalsoaDoyoufindit'sgettinghardertogetaround?smallriskofinfectionofthenewjoint,orthenewOhyes,certainly.jointcomingloose.Ifeitheroftheseoccur,thenyouDoesyourhipcauseyouanyproblems?mayneedaseriesofoperationstoputtheproblemYes,it'ssostiffIcan'tbendovertotiemyshoeright/correctit/.laces.Doanyproblemsruninthefamily?81RHEUMATOIDARTHRITISYes,mymotheralsohadastiffhipandshehada᤺limp.SheneededanoperationwhenshewasonlyGold=concentratedmarijuana}~ᜧfortytogiveheranewhip.rosehipᴮNow,I'dliketoexamineyou.CanyoupleasetakeAchilles,tendon.Ύ/Achilles*tendonᑭyourclothesoff.That'sgood.Andnowstandup.I'd"_(Ύ:ḄΎᜮᓽ▬justliketomeasurethelengthofyourlegs.Good.Ḽ◖Nowifyoucouldlieonthecouch.That'sgood.untitussive/tussiveShowmehowwellyoucanmoveyourhip.Good,houseboundg¡nowI'dliketomoveit.I'llbenditdownanddrowsy¢¢£ṑ42
43getabout,TobeoutofbedandbeginningtowalkThepainisonlyinmyrighthip.again,asafteranillness.¥¦§ ¨©ª«©¬¦§®ᢣwIt'salwaysworseinthemorning.attimes,Onoccasion;sometimes.ᨵ±²³ᡈIhavetousetwostickstogetabout.ᦻIt'salwaysworsewhenFvedonealot.RheumatoidarthritisGentleexerciseisnotaproblem.Whatproblemsdoyouhavewithyourjoints?Igetalotofpainandstiffness.Yes,I'mtakinguntitussives.Hasthisbeengettingworserecently?Yes,Tmtakingmusclerelaxants.Yes,overthepastfourmonthsI'venoticedageneraldeteriorationinsymptoms.Itmakesmehousebound.Whichjointsaremainlyaffected?Itmakesmedrowsy.Itusuallyinvolvesmyhands,kneesandshoulders,butsomedays1feelgenerallysoreallover.82PHYSIOTHERAPYIsthereanytimeofdaywhenyoursymptomsarePhysiotherapyworse?Doctor,yourecommendthatIsawaphysiotherapistYes,IfeelverystiffinthemorningwhenIgetup.formytenniselbowwhenIlastvisitedyou.SheHowlongdoesthislast?mentionedatreatmentcallediontophoresis,whatOh,atleastanhour.Sometimeslonger.doesthisinvolve?HaveyounoticedanythingthatmakesthesymptomsWell,MrFoster,thatinvolvesputtingsomecreamonworse?theskinovertheelbowandthenusingaspecialYes,ifI'vehadabusydayorI'mdoingheavyelectricaldevicestoencourageittopenetratetheskin.houseworkmyarthritisismuchworse.Doyougetalotofpainatnight,andifso,doesitWell,MrFoster,thisinvolvesputtingelectrodesondisturbyoursleep?theskinoverthemuscleandstimulatingtheRecentlyI'vefoundthatIwakeupwheneverIturnelectrodestomakemuscletwitch.Thishastheoverbecausethismakesmyshoulderpainworse.advantageofstraighteningthemuscles,andit'smoreWhattabletsareyoutakingatpresent?comfortablethanwhenyoutrytocontractthemuscleI'mtakingibuprofen.yourself.Andfurthermore,thestimulationcangiveHaveyouhadanyproblemswiththem?youstrongerandcontractionthanyouareabletoIsometimesgetindigestionandheartburn.manageatthemoment.Haveyouhadothertreatmentsinthepast?ItriedGoldinjectionsbeforebutitwasstoppedafterDoctor,thephysiotherapistrecommendedultrasounddevelopeditchingandarash.treatmentformyankle.DoyouthankthisisagoodHowdoesyourarthritisaffectyourlife?idea?IfounditdifficultsometimestodressandwashingYes,verymuch.Theultrasoundisaveryspecialcanbeaproblem.It?ssometimesdifficulttocombkindofpulsewavesencouragethehealingofthemyhairandIfoundhouseworkdifficultattimes.tissueofyouankle,thisisveryeffective.IalwaysdrinkrosehipteaDoctor,thephysiotherapistrecommendedexerciseIhaveverylittlemovementinmyhip.formyshoulder,doyouthinkthisisagoodidea?Yes,thephysiotherapywillmovethejointherselfFvetornmyAchilles,tendon.throughasbigarangeofmovementaspossible43
44withoutcausingyoutoomuchdiscomfort.ShewillsofteningofthebonecausedbyalackofvitaminD.alsoencourageyoutomovethejointyourself.ThetreatmentistoaddsomevitaminDsupplementstoyourson'sdietandalsotogetsomefreshairand83FLATFEETsunlight.Flatfeet85THYROIDISMbunionµ¶·"ᜧ¸ᑁ¹Ḅº·(Thyroidismcom9»¼Doctor,Tvegotswellinginmyneck.Howlonghaveyouhadtheswelling?Comein,MrScottandhaveaseat.MynameisRoughlythreemonths.doctorJones.HowcanIhelpyou?Isitgettinglarger?Doctor,myfeetterriblysoreandmylegsache.It'sIt'sslowlygettingbigger.particularlybadattheendofalongdayandItireIsitgivingyoutroublewithbreathing?veryeasily.Ican'tstayonmyfeetforlongatall.Veryoccasionally/rarely/.Howlonghaveyouhadthisproblem,MrScott?Haveyounoticedanychangesinyourvoice?Fvehaditforseveralmonthsbutit'sbeengettingaNo,butsometimesIfindthatfoodsticks.lotofworserecently.Haveyounoticedanychangesinyouweight?Standupforme,please.Standupstraight.That'sFvelostseveralpoundsoverthepastcoupleofgood.Nowstandonyourtiptoes,nowonyourheels.monthssincetheswellingbegan.Walkontheouteredgesofyourfeet.MrScott,youDoyoulikehotweatherorcoldweather?haveflatfeet.IthinkthebesttreatmentisaninsoletoWell,Iprefercoldweather.Ifeelmorecomfortablereinforcethearchofyourfoot,Inoticedalsothatyouthen.haveanumberofotherminorfootproblems,youDoyoufeelhotandsweaty?havecomsonyoursecondandthirdtoes,andyouYes,Ievenfeelsweatywhenit'scold.arebeginningtodevelopabunionnearyourtoes.IDoyougetpalpitations?thinkthebesttreatmentforthisistowearsomeYes,Ioftenfeelmyheartpounding.broad,comfortableshoes.MayIexamineyou?Well,itappearstomethatyourthyroidglandisabitenlarged.Wemustadminister84RICKETSsomebloodteststocheckonthefunctionoftheRicketsthyroidglanditself.ItwellhelptofindoutifitisDoctor,I'mveryworried,myson'slegsarebent.overactiveorunderactive.WellalsoperformsomeYes,Icanseethat.Howlongagodidtheproblemscans.Oneofthesewillinvolvetheuseofsomestart?radioiodine.Thesewouldmeanyou'llgetalittleItbeganwhenhewasabouttwoyearsoldandit'sdrinkofaverylowleverofradioactiveiodine.We'llbeengettingworsesince.thenscanthethyroidglandsoseewhetherit'stakingHowoldisyoursonnow?upalotoftheisotopeornotenoughoftheisotope.He'sfour.ThisgivesusanindicationofhowwellthethyroidisDoeshehaveanyotherproblems?functioning.SinceyouhaveswellingoftheglandYes,hischestisaratheroddshape.we'lldoanultrasoundscanaswell;thisislikeusingHasyoursoneverhadanyabdominalorkidneyechosoundsandit'Hgiveussomeideaofwhetherproblems?Doeshehaveanunusualdiet?theswellingyouhaveinyourglandissolidorcystic.HedoeseatpoorlyandasaninfanthewasAinvestigatedforfailuretothrive...Amiddle-agedlady,aboutfortyyearsold,hasMrMohammed,yoursonhasrickets.Thisisanoticedanenlargementinthefrontofherneck.She44
45hasalsonoticedthatatthesametimeshewaslosingSheisgivenanoperationforsubtotalthyroidectomyweight.Shewashavingnightsweats,tremorsoftheinwhichtheexplorationoftheneckiscarriedouthands,andfromtimetotimenoticeablepalpitationundergeneralanesthesia.Theusualpreoperativewhichcouldbedescribedasfeelingherheartbeat.antithyroiddrugisemployedtobringthepatientintoThedurationofhersymptomsisaboutthreeyearstheeuthyroidstatebeforeoperation.andsheconsultedherdoctoraboutthissomesixFweeksago.Thedoctorobservedthelossofweight,Theincisionoftheskinismadetransversallyintherapidpulse,thesmoothskinandthyroidswelling,creaselineoftheneckwhichresultsinavirtuallyandhasreferredherfbrtheconsultation.invisiblescarafteraperiodoftwotothreeyears.BFollowingsomeroutinebloodtests,notably,forhemoglobinlevels,whitecellcountsandforthyroid86PROBLEMSOFTHE(O)ESOPHAGUShormonelevelsshewillalmostcertainlybeadvisedProblemsofesophagustohaveanoperation.DrugtherapyisadvisedintoxicDoctor,Tvebeenhavingtroubleeating.WhenInodulargoitre.Sheisalsoadvisedthatshewillneedswallowfooditseemstogetcaughtinmychest.tobeadmittedtoahospital/hospitalized/fairlysoon,Doyoufindildifficulttoswallowsolidfoodordoinotherwords,withinamatterofthreeorfourweeks,youhavetotakeliquidsorcanyounotevenmanageifpossible,fortheoperationtobeperformed.Sheisliquids?toldthattheoperationremovestheenlargedportionIfindthatthinglikemeatorpotatostick,and1haveofthegland,butwillleaveherwithasufficienttotakeadrink,towashitdown.amountofthyroidtissuefornormalmetabolism.Howlonghaveyouhadthisproblem?CForaboutthreemonths,butI'mfindingitThegeneralphysicalexaminationofthislady,whichincreasinglydifficulttoswallowfood.concludestheconsultation,revealsthatshehasaHastherebeenanyassociatedpainorvomitingwithweightofonlyfiftyninekg,shehasinthepastbeenthis?asheavyassixtyfivekg,sotherehasbeenaWhenIeatsolidfood,IfinditsticksbutafterTvesignificantweightloss.Herbloodpressureisbroughtitupthepaingoesaway.somewhatraised/elevated/inviewofherage,justInthepasthaveyouhadanyproblemswithburningoverforty.Herrestingbloodpressureisonehundredinthechest,especiallywhenlyingdownorafteraandfortyoverninetyandshehasaconstantlyrapidlargemeal?pulseintherangeofeightyeightandninetysix,I'vehadheartburnafterFveeatenalotoratnight,orwhereasonewouldhopeforittobeintherangeofaftersomekindsoffood,forabouttenyears.seventytwotoeighty,Haveyoulostweightorhadlossofappetite?dYes,TvelostaboutfourkilosoverthelastthreeTherestofherhistoryisnon-contributory.Sheisamonths.marriedwomanwithtwosmallchildrenagedeightWhenyoueatdoyoufeelasifyouarechoking,orandten.She'shadnoseriouspreviousillnessesanddoyoucoughalotafterwardsordoyoufeeltightshe'snotnoticedanyothersymptomsapartfromaaroundyourchest?slightincreaseinappetitewhichrathersurprisedherNo,Idon'tgetanythinglikethat.inspiteofherweightloss,thereisnofamilyhistoryCanyoupleasegetintoagownandI'llexamineofthyroidenlargement.She'sacceptedtheadviceyou....WiththesesymptomsIthinkweneedtofindandwillcomeinforanoperationwhensentforinoutwhetherthereisablockageinthefoodpipeoraboutamonth'stime.theesophagus.Wecandothisinanumberofways.EOnewayistoputatubedownyourthroatwhichcan45
46lookintotheesophagusanddownintoyourstomach.wemayrecommendremovingthegallbladder.IftheAnotherwayistogiveyouabariummeal,youhavetestdonotshowstones,weneedtolookforothertodrinkathickliquidcalledbariumwhichwillreasonsforthepain.outlineifthereisanyblockage.Theblockagemaybeduetoanumberoffactors.Itcouldbeduetoa88APPENDICITISgrowthorfromatighteningoftheesophagusduetoAppendicitisacidgoingupintoit.Thisiscalledreflux,afterthesetwotestswecandecideuponatreatmentplan.sickleavewᎷWhatbringsyouintoseemetoday?87GALLBLADDERDISEASEWell,Tvebeenhavingpainaroundtherightsideof᤺mystomach.chippl.$½¾¿ÀᱏHaveyoufeltsickorbeensick?/haveyouvomitedorbeennauseous?GallbladderdiseasesNo.Whalbringsyouintoseemetoday?Canyoudescribethepaint?WhereitbeganandFvedevelopedthisveryseverepainwhichcameonwhereitisnow?veryquicklylastnightafterIhadfishandchipsforThepainstartedyesterdayaroundmybellybuttonmysupper.Icalledmydoctoroutandhegavemeanandthenmovedowntotherightside.It'sadullachyinjection,andthepaingotbetterbutIstilldohaveakindofpain.dullacheundermyribs.Doyoufeelhungry?haveyoueatentoday?Haveyouhadthepainbeforewhenyou'veeatenfatIdon'tfeelhungrynowalthoughIhadbreakfastfood?earlierthismorning.Yes,butneverasbadlyasthis.Haveyouhadanyhotshiveryturnsorchills?AnyDoesthepainmoveanywhereordoyoufeelitproblemswithyoururination?Anybackpain?Anyanywhereelse?changeinyourbowelmotion/movements?Ifeelitonthetopofmyrightshoulder,andit'sgoneNo.I'vehadnoneofthose.throughtomyback.HaveyouhadanycoldsortroublewithyourchestHaveyoubeensick,orhaveyoufeltsick?/haveyouoverthepastweek?vomitedorbeennauseous?/No,Ihaven't.Yes,Ivomitedseveraltimesduringthenight,Haveyouhadanydiarrheaoverthepastfewdays?althoughthatdoesn'tmakethepainmuchbetter.No.Hasanyoneinyourfamilyhadgallstone?CanyoupleasegetintoagownandI'llreturnandYes,mysisterhasalotoftroublewithherexamineyou.DoesithurtwhenIpresshere?gallbladder.Ouch!IthinkFilneedtoexamineyounow.CouldyouDoesithurtwhenIletitout?pleaseputonagownandIllbeback....Um,IthinkOuch!youmighthaveproblemswithyourgallbladder.WeIthinkthatthereisagoodpossibilitythatyouhavearegoingtodosomebloodteststodetermineiftheappendicitis,althoughonecan'tbesure.We'llgetliverfunctionhaschangedinanyway,andwearesomebloodtestslookingyourwhitebloodcount,goingtodoanultrasoundscan.Itinvolvesamachinehowever,basedonyoursymptoms.Ithinkitwouldplacedovertherightsideofthestomachandsoundbewisetoadmityoutothehospital,andputyouonawavesareproducedwhichwillshowifyouhavedrip/startyouonanIV/,andifyoudon'timprove,stoneornot.DependinguponwhatthesetestshowthenIthinkweshouldremovetheappendix.46
47No,no.that'swhatwe'reherefor.It'simportanttoI'vegotarightbackpain.lookatalltheselumpsandbumpswherevertheyare.I'vegotapainontherightsideofmylowerWouldyoupleasetakeoffyourclothesdowntotheabdomen.waistsothatIcanexamineyou...I'mgoingtoFvegotageneralabdominalpain.examineunderyourarmpitbecausesometimesthereareglandstherewhichmaybeenlargedwhenyouIamalwaysseasickontheboattrip.havealumpinthebreast...andalsoI'mgoingtoI'vebeenonsickleavefortwodays.examineyouneckbecausesometimesthereareIhaven'tfeltnauseaorvomited.glandswhichbecomeenlargedwhenyouhavealumpinthebreast.Thefirstthingwe'lldoissendIt'sastinging,burningsensation.youforamammogramtoseeifthelumpissolidorIt'sacramping,stabbingpain.cysticoriftherearecalciumdepositandthenwe'llIt'sabackpain.doabreastbiopsy.FilinsertaneedleintothelumptoobtainatissuesamplesothatwecansendittoaItmovedupmyshoulderandthenIhadaheadache.pathologistforexaminationtodeterminethenatureIttraveleddowntomybackandthentotheleft.ofthecells.Itstartedinthemiddleofmystomachandmoveddowntotheright.90GOODANDBADNEWSGoodandbadnews89BREASTLUMPSI'mverypleasedtosaythatyouhaveaBreastlumpstraightforwardandsimplefracture.AssoonasthemammogramÂÃXÄ᯿ᱏplasterwasremovedandthemuscleshaverecovered,Doctor,IfoundthislumpinmybreastwhenIwasyou'llfindabsolutelynodifferencefromyourhaving/taking/abaththreedaysago.previousstateandwillabletofunctionnormally.HaveyounoticedanypreviouslumpsinyourbreastWell,Tdlikeyoutoknowthatthefractureyouhaveorhaveyouhadanypreviousproblemsinyourisclosedtoabloodvesselandanerve,andbecausebreast?ofthiswemayhavetooperatewhenwereducetheYes,IfeltasmalllumpwhenIwasinthebathfracturebecausethearterymaybedamaged.Wemayseveralmonthsago,andthatlumpcomesandgoeshavetoreplaceasectionofthearteryandthenervewithmyperiod.mayhavetobefreedatthetimeofthereduction.Doesthatoldlumphurtatall?I'msorry,afteryouroperationwefoundthatweNo,notreally.wereunabletorepairthefracturecompletely.Okthisnewlump.Hasitbeenpainful?Consequently,you'llfindthatyou'llhaveastiffknee,Justalittletender.however,withtimeyou'lladapttothisconditionandHaveyounoticedanychangeinsize?shouldn'thavetoomuchdisabilityandlongrun.Well,thelumpgetslargerandsmallereverymonthwithmyperiods.91HERNIAHaveyounoticedanydischargeoranybleedingfromHerniathenipple?Thedaybeforeyesterday,whileliftingawinebarrel,Yes,whenIsqueezemybreast,asmalldropofIfeltacrack/sharppain/inmyleftgroin.Thenayellowishbloodyliquidcomesoutofthenipple.Butlittlelumpcameoutwhichhasgrown.Ithurtsitdidn'thurtandseemedsoimportant.Ireallydidn'tsometime,especiallywhenIleftsomethingorcough.wanttotakeupyourtimewhenIknowyouaresoIsyourbowelmovementregular?busy.Yes.47
48Canyoupushthelumpback?Doyouknowifyouhaveanykindofheartcondition?Yes.IfIlieonmybackitgoesbackbyitself.Doyouhavehighbloodpressure?Howhighisit?Right.GetuponthecouchandI'llhave/take/alookDoyouexperienceanyirregularheartbeat?atit.Itwillhavetobeoperatedonsoon,otherwiseifDoyoudrinkalcoholregularly?howmuch?youcan'tpushitbackitbecomeshardandpainful.Haveyouhadanyproblemswithyourliver?Doyoutakecontraceptivepillsregular?92EMBOLISMEmbolismGeneralanesthesiaAbouthalfanhouragoIfeltasharppaininmyleftWearegoingtogiveyouaninjection,youUIfeelcalf.Icouldhardlystayonmyfeet,itwassopainful.yourselfgoingtosleep.TilgiveyousomeoxygentoCanyoumoveyourtoes?breathethroughamask.We'llgiveairanestheticYes,buttheyhurtterriblywhenImovethem.now.breatheevenlythroughnose.YoumayfeelaDoyouknowifyouhaveanyheartproblems?littledizzy.Don'tbeworried.Haveanicesleep.Yes,Iwastreatedforarrhythmia.Iwasgivenanticoagulanttablettothinmyblood.Istoppedlocalanesthesiatakingthemsixmonthsago.I'mgoingtowashyourbackwithsomeantiseptic,itIt'spossiblethatatinybloodclothasblockedoneofmaybeabitcold.You'llfeltasharpsting.Tmgoingthelegarteries.Ifthat'sthecaseyou'llneedantogiveyouaninjection.Relax,don'tmove.Curlupurgentoperation,Fmafraid.intoaball,tellmeifyourbackgoesnumboryoufeelasharpshockinyouleg.Trytomoveyourlegif93AN(A)ESTHESIAyoucan,I'mgoingtojabyourleg.TellmewhatyouAnesthesiafeel.Haveyouhadanoperationbefore?Haveyoubeengivenageneralanesthetic?WakingthepatientupHaveyoueverhadaninjectionintoyourspine?Mrsbrown,pleasecough.Takeadeepbreath,Haveyoueverhadaspinalanesthetic?swallowandspitoutwhatyouhaveinyoumouth.DidyouhaveanyproblemsorcomplicationduringTheoperationisover.Wakeup,doyoufeelsick?Ororafteranesthesia?areyouinanypain?Areyouallergictoanydrugs?Haveyouhadanyproblemswithyourheartorlungs94SKINAPPENDAGESbefore?᤺Doyougetheartburn?Ringwormᷯ/Fungi(pL),fungus31/paronychiaDoyouhavetoomuchgastricacid?ᵬÈ·/tineabarbaeÉᷯ/alopecia,Êu,HaveyouhadanyproblemswithyourspineoranyalopeciaareataÌ▲ឋῃu,ᦿÊ,/areataÐÑḄ/neurologicaldisease?flareupÒu/hayfeverÓn/oozeÕ¡/burstHowdoyoubearstress?ẚ×/Nailfoldᵬ⋨Doyouexperienceshortnessofbreath?Doyourlegswell?Areanyofyourteethloose?ᦻDoyouhaveanycapsorcrowns?Doyouhaveanyremovabledentures?DermatologyCanyoubreatheeasilythroughyournose?Doyouhaveacoldoracough?SkinappendagesDoyouhaveanydiseasethatweshouldknowabout?Areyoudiabetic?One,Paronychia48
49Two,alopeciasomethingyoucandoaboutit.Three,tineabarbaeHaveyoueverhadasthma,hayfeveroreczemaorHowlonghaveyouhadproblemswithyournail?hasanybodyinyourfamilyhadtheseconditions?It'sbeenswollenandsoreforsixmonths,andYesIhadeczemawhenIwasyounger.occasionallypusoozesoutfromit.Hasanybodyinyourfamilyeverhaddiabetes,Haveyouhadanytreatmentforit?arthritisoranythyroidproblems?Yes,thedoctorhasgivenmesomecream,butitNo,I'msuretheyhaven't.hasn'thelped.Haveyouhadanytreatmentforthehairlosssofor?1thinkwhatyouhaveisparonychia,andFilNo,thedoctorjustsentmeuphereforyouropinion.recommendatreatmenttoyourdoctorwhenIwriteTheproblemiscalledalopeciaareata.That'srathertohim.Thisisaninfectionofthenailfoldwhichdifficulttotreat,butwhenthere'sasmallareatendstogoonforquitealongtimebeforeitclearsup.affected,suchasyouhave,wecantreatitbyItrequirestreatmentforatlesssixmonthsandyouinjections.YouneedtohaverepeatedinjectioneveryneedtokeepusingthetreatmentthatIrecommendsixweeks,andinyourcaseitshouldbeeffective.duringthattimewithoutabreak.It'sduetofungusinthenailfold.Ifitflaresupatanytimeandgetsworse,95PSORIASISyoushouldgotoseeyourdoctorbecauseyoumay᤺needsomeantibiotics.DithranolAcetateÙ⏒1,8,9-᠄Ü,1,8,9-᠄ÜÝ⏚ßᢙàáᷯ&IbelievethatyouhaveproblemswithyourbeardTar=gumopiumᱏãarea.DovenixäåỚçᨒᢙéê&Yes,TvehadproblemswithpainfulspotswhichMethotrexateᵬëìíîïðῃ,ñòëᵬìíëcometoahead,andburst.Itflaresupfromtimetoᵬìíëóëᵬôõ⏚ëᵬtime.retinoidö÷2A,÷2Aö÷ᵬ⏚öWhattreatmenthaveyouhadforit?cyclosporineAø2A"ùúᢓᑴᑺ(Mydoctofsgivenmeashortcourseofantibioticswhichhasnotbeeneffective.psoriasisYouhaveaconditioncalledtineabarbae.TilsuggestatreatmenttoyourdoctorwhichshouldbeeffectiveIbelievethatyouhaveproblemswithyourscalp.inclearingitup.It'sduetoaninfectionwhichisYes,Tvehadscalingofthescalpwhichstartedaboutspreadbyshaving.Itwouldbebetterforyoudidnottwomonthsago,andhasgraduallybeengettingshavewithwater.Tvetakenaswabtodetermineworse.Ithasalsobeenitchy.whatbacteriaarecausingtheinfection.ThetreatmentHaveyouhadanytreatmentforit?willdependontheresultfromswabwhichbebackinYes,mydoctor'sgivenmeT-Gelshampoo,butithasaboutoneweek'stime.notbeeneffective.Yourappeartohavepsoriasisinvolvingthescalp,IHowcanIhelpyou?wouldsuggestyouuseadiprosalicscalpapplicationFvebeenlosingmyhair.whichshouldberubbedinatnightandleftovernight,Areyoulosingitinsmallpatchesorallover?washedoutinthemorningwithatar-basedshampoo.There'sonesmallpatchwhichisfallingoutontheYoushoulduseiteverynightuntilithassettled,andtopofmyscalp.thengraduallyreducethefrequencywithwhichitisHowlonghasthisbeengoingon?applied.It'sbeengoingonforthelasttwomonths,andthepatchisgraduallygettingbigger.Iwonderifthere'sTheletterfromyourdoctorsayyouhavepsoriasis,49
50 Z/whendidthisfirststart? I'vehaditfortenyears,butI'veneveractuallyhadWhathasyourproblembeen?tobesenttohospital.I'vehadcoldsoresonmyupperlipwhichhavecomeWhendiditflareup?onfromtimetotime.ItstartedflaringupabouttwomonthsagojustaboutWhenwasthefirsttimeyougotthem?thetimeIwassittingfor/taking/myexams.Fvehadthemforyearsnowbutlatelythey'vebeenWhichpartsareaffectednow?comingupmorefrequently.I'vegotitallovermybody.MyarmsandlegsandDotheylooklikewaterblisterswhentheycomeup?myscalparescaling.Yes,theystartaswaterblistersbutthenbreakdownCanyoupleasejustgobehindthescreenandundresstoformscabs.andlieonthecouchunderthesheet.DoesanybodyWhendothecoldsoresbreakout?elseinthefamilyhavepsoriasis?TheytendtocomeonwhenIhaveacoughorcold.Yes,mygrandmotherhadit.IthinktheywouldbebesttreatedwithacreamcalledUnfortunately,it'snowverywidespreadanditwillZovirax,whichyoushouldapplywhenyoufirstfeelbedifficultforyoutotreatyourselfathome.Thetinglinginyourlipwhichsuggeststhattheblistersbestwaytogetitclearedwillbetocomeintoarejuststarting.Il'sduetoaviruswhichispresentinhospitalwherewe'lltreatyouwithregulardressingsthenervesandcancometothesurfacewheneveryouwithtar-pasteandultravioletlighttreatment.You'llareunderanyformofstress,suchasanotherillness.probablybeinhospitalforaboutfourweeks.97ACNEChronicplaquepsoriasisisaninheritedconditionacnewhichnormallyoccursovertheextensoraspectsofHowlonghaveyouhadproblemswiththespotsandtheelbowandkneesbutcaninvolveanypartofbody.pimples?Othersitesthatareaffectedarethenails,scalp,Fvehadacneonmyfaceforthelastfouryears.Tmumbilicus,andoccasionallythereisflexural,orwhatnow17andtheystartedwhenIwas13.issometimescalledinversepsoriasis.TheplaquesHaveyouhadanytreatmentforit?arewelldemarcatedwithsilveryscalewhichleavesThedoctorgavemetetracyclinefortwoweeks,butitpin-pointbleedingwhenthescaleisremoved.Therejustgotworsewhenthetabletswerestopped.isahierarchyoftreatment,startingwithtopicalHaveyouusedanycreamsorointmentstorubinthetreatmentconsistingeitherofdithranol,tarorskin?dovenix.TopicsteroidsareoccasionallyusetohandsYes,Igotonefromthechemistbutithasn'treallyandfeedforflexuralpsoriasisorforthescalporthebeenhelping.face.Unfortunately,whenyouuseantibioticsforacne,UltraviolettreatmentincludingUVBandPUVAaretheyhavetobecontinuedformuchlonger.Iwouldalsouseful,iftheseareineffective,thenseveresuggestinthefirstinstanceyoutaketetracyclinetwopsoriasismustbetreatedwithsecondlinetherapy,tabletstwiceadayforatleastthreemonths.Thesethemaindrugsusedforsecondlinetherapyincludemustnotbetakenwithfood,soIsuggestyoutakemethotrexate,retinoidandcyclosporine-A.allthetwointhemorning,halfanhourbeforebreakfast,drugshaveserioussideeffectsandsotheyareonlyandtwointheevening,halfanhourbeforeyourusedwhenotherformsoftreatmenthavefailed.eveningmeal.Youshouldtakethemwithwaterratherthananymilkysubstance.Pleasecomeback96HERPESSIMPLEXandseemeinthreemonths.Herpessimplex98WARTSZovirax᧖ýþÿ ᵞ ᧖ᑴᑺḄᖪ50
51Wartsintheafternoon.Ifnecessary,wearahigh-factorsunHowlonghaveyouhadproblemswithwarts?block.Theystartedoneyearagobuthavegraduallybeenspreadingovermyhands.100ECZEMADoyouhavethemonanyotherpartsofyourbody?Betnovate⏚No,they'rejuslonmyhands.What'syourjob?Howlonghaveyouhadproblemswitheczema?Unfortunately,IserveschoolmealsIcan'tcarryonItstartedwhenIwasababy.with/continue/myjobwhileIhavewarts.Isthistheworseit'severbeen?Isee,wewilltreatthemwithacoldspraywhichisYes,itflaredupabouttwomonthsagoandnoneofliquidnitrogen.TheymayhavetobetreatedeverythetreatmentsI'vehadfromdoctorshasbeenthreeweeks.Itwillbemoreeffectiveifyoutreateffective.theminbetweentimeswithawartpaint.YoumustWhattreatmentshaveyouhad?soakyouhandsforfourorfiveminutesintheFvebeenusingBetnovateonmybodyandeveningandthenrubthewartdownwithapumicehydrocortisoneonmyface.stoneoremeryboarduntilit'sflat,youcanthenDoYouknowofanythingwhichmighthavecausedapplyawartpaintandleaveitonovernightandittoflareuprecently?removeitinthemorning.ItmaytakesometimetoI'vejustchangedjobs,andI'mworkinginafactoryclear,butsolongasyouapplythetreatmentwhereIcomeintocontactwithoil.Itstartedonmyregularlyitshouldbeeffective.handsandthismaybewhatiscausingitstartupagain.99MOLESMolesIthinkthebestwayoftreatingyouwillbetodoWhatseemstobetheproblem?dailydressingwhichwillallowtheskintosettleIhavesomemolesonmybackandthedoctormuchmorequickly.Afterithassettled,we'llarrangethoughtIoughttocomealongtogetthemcheckedforpatchteststobecarriedouttodeterminewhetherout.youarereactingtoanyofsubstanceyouarecomingHaveanyofthemchangedrecently?Havetheyintocontactwithatwork.Thiswillrequirethreebecomedarkerincolor?Havetheychangedshapeorvisitstohospital.Thepatcheswillbeputonyourgrowninsize?backatthefirstvisitandremovedonyoursecondMywifesaystheyaregrowingandhavebecomevisit.They'llbereadatthattime,andyou'llhavetodarkerincolor.comebacktwodayslaterincasethereareanylateHaveyouhadanyitchingorbleedingfromthem?reactions.Ifyou'repositivetoanyofthepatches,No,there'sbeennoitchingandtheyhaveneverbled.we'llbeabletogiveyouadviceaboutavoidingHaveyouhadmuchsunexposureinthepast?contactwiththissubstance.Igoonholidayabroadeverysummer,butIusuallytaneasilyandFveneverburntmyskin.There'sonemoleonyourbackwhichIthinkneeds101FUNGALINFECTIONStoberemoved.This'llrequiresomelocalanesthetic.fungalinfectionWeUlcutitout,putinsomestitcheswhichyou*11getoutatyourowndoctor's.IwouldadviseyounottoWhat'stheproblem?exposeyourselftothesun.ThebestwayofI'vehadanitchyrashonmybodyandarmsandlegsprotectingyourselfistowearlightclothingandtoforthelasttwomonths.stayoutofthesunbetween11inthemorningand3Canyoudescribetherash?It'spinkwithflat,ovalspots.51
52Wherediditstart?meinaboutfiveweeks'times.Iftheresultispositive,Itstartedonmychestandhasspreadtomyback,mywe'Hbeabletotreatitwiththree-monthscourseofabdomenandmyarms.tablets.Haveyouhadanyproblemswiththisbefore?Yes,twoyearsagoIhadasimilarproblemwhichtineaunguiumᵬᷯwastreatedwithSelsunshampoo.Youhavewhatiscalledpityriasisversicolorwhichis102LEGULCERduetoafungusontheskin.TilgiveyousomecreamLegulcertotreatthis.Unfortunately,peoplewhogetthisHowlonghaveyouhadproblemswiththisulcer?conditiontendtohaveproblemswithitagainafteritItstartedwithaninfectionaboutthreemonthsagohasbeentreated.andhasneverhealed.Haveyouhadproblemswithvaricoseveinsorpityriasisversicolorᦿᷯ,thrombosisorpulmonaryembolism?Yes,aboutfifteenyearsagoIhadathrombosisinmyWhafstheproblem?legandwasadmittedtohospitalwithchestpainandFvehadanitchyrashbetweenmytoesforyearsbut,coughingupblood.Iwastolditwasbecauseoftheunfortunately,ithasgotquitealotofworserecently.thrombosisinmyleg.WillyoupleasetakeoffyourshoesandsockssothatBecauseyou'vehadthrombosisinthepast,you'reIcanhavealookatyourfeet,andifyoucouldmorelikelytodeveloptheseulcers.Theywillhealupspreadyourtoesrilabletoseeit...Oh,youhavethemselvesbut,unfortunately,it'lltakesometimewhatiscalledtineapedisorathlete'sfootwhichisandrequiresregulardressings.Asyourlegisswollen,duetoafungus.Tilgiveyouacreamwhichshoulditwillbenecessaryforyourlegtobekeptelevatedbeputonfourtimesaday.Unfortunately,itwilltendwhenyou,resittingatrest.I'llalsogiveyouantorecurbutithelpstowearlightfootwearaselasticstockingtohelpreducetheswellingwhichopposedtotrainers/sneakers/tennisshoes/whichtendwillallowtheulcertohealupmorequickly.Tiltomakethefeetsweatandtendtomakethefungalarrangeforthedressingstobedoneregularlybytheinfectionworse.districtnurse.tineapedisᷯ103URTICARIAUrticariaHowlonghaveyouhadtheproblemswithyournails?Itstartedaboutayearago.Now,what'stheproblem?Whichnailsareinfected?ForthelastthreemonthsI'vehadproblemswithanFvegottwonailsonmyleftfootandoneontherightitchyrash.footwhichhavebecomeabnormal.Whereaboutsdoesitoccur?WillyoutakeyourshoesandsocksoffsothatIcanIgetitallovermybody,includingmyarms,legs,seethem?Aha.yousee,yournailshavebecomeandhandsand,occasionally,itaffectsmyfaceandwhite,opaque,thickenedandbrittle.Itlookslikeamyupperlipisswollen.fungalinfectionofthenailcalledtineaunguium.ToHaveyouhadanyswellingofthetongueorinsidetrytoidentifythefunguswhichiscausingit,Filtakethemouth?aclippingfromthenail,whichwe'llsendofftobeNo.lookedatunderamicroscopeandthenwe'HtrytoHaveyoueverhadanyproblemsbreathing?growafungus.ItwilltakeaboutfourweeksfortheNo.resultstocomebacksoyoumustcomebackandseeAreyouquitewellotherwise?52
53Yes.thinktheproblemiserysipelas.YouhavetobeHaveyoubeentakinganytabletsorhadanyadmittedtothehospital,lobetreatedwithvaccinationsrecently?intravenousantibiotics.ItshouldsettlequitequicklyNo.I'venottakenanytabletsforaboutthreeyearsandyoushouldbeabletogohomeinfourorfiveand1haven'tbeenvaccinatedforabouttwoyears.days.Arethereanyfoodsthatyou'venoticedthatcancauseit,ordoesitcomeonduringtheexercise?Erysipelas012No.Ihaven'tbeenabletoidentifyanycauses.Howlongdoesthelastwhenitstarts?105SCABIESItcouldbethereinthemorninganditwillbegoneScabiesbytheevening.Doesiteverlastanylongerthanthis?FvegotanitchyrashwhichisdrivingmeabsoluteNo.itdoesn't.wild.Doyouevertakeaspirinasaheadacheremedy?Howlonghasitbeenthere?No,Ionlytakeparacetamolsometimes.I'vehaditforthreeweeksandmywifeandFdliketodosomebloodteststodeterminewhetherdaughter'vestartedtodevelopanitchyrashaswell.thereisanyunderlyingcauseforyourrash,duetoHaveyouhadanytreatmentforityet?whatwecallurticariawhich,unfortunately,maygoMydoctorgavemeEurax,butitdoesn'tseemtobeonforsometimebeforeitgetsbetter.Wemaynothelping.findthecauseforit,butitcanbetreatedquiteWhichpartsaremostlyaffected?successfullywithregularantihistamine.TilgiveyouI'vegotitbetweenmyfingersandallovermybodyanotetotaketoyourdoctor,sothathecanprescribebuttheitchisfromheadtotoe.adailydoseof10mgofZyrtec.Canyoupleaseshowmethepartsthatareaffected?Justtakethingsoffbehindthescreen.Youcertainlyurticaria seemtohaveevidenceofscabies.Thereareburrows,Zyrtecᱯ"#$cetirizinedihydrochlorideீᢙ()andriltrytoextractoneofthemitesfromthe*+burrow.I'llarrangefbryourdoctortoprescribeyouparacetamolᡫ-./someQuellada.Thiswillhavetobeusedbyallthefamily.Youmustbetreatedfromtheneckdownanditmustbeappliedtoalltheskincreases.Youhaveto104ERYSIPELASchangeallyourclothing,andbeddingandchangeallErysipelasthetowelsandrepeatthetreatmentoneweeklater.Itshouldsettle,though.What'stheproblem?Ihaveapainfulareaonthesideofmyfaceandit'sQuellada33334ᓄ634 78ᩔ:*graduallybecomingmoreandmoreswollen.Eurax;<ᦣ#ᢙ>ᷯ*+Whendiditstart?Itstartedyesterday.Howareyoufeelinggenerally.106GOODANDBADNEWSIfeelveryshiveryandgenerallyundertheweather./1GoodandbadnewshaveshiversandIdon'tfeelwell.Iseethatthewholeright-handsideofyourfaceisMrsSmith,twoweeksagoyouhadblackmoleswollenandredanditisdifficultforyoutoseeoutremovedfromyourleg.Wenowhavetheresultofofyourrighteye,andyourhaveatemperature.IhistologyavailableandI'mpleasedtotellyouthatit53
54wascompletelybenignandshouldthereforecauserealizedthatitisjustaspeckledmole,whichdoesn'tyounofurtherproblem.Thereisnotneedformetolookatallsinister.However,sheisabitworriedityouagainattheclinic.andreallywantsitremovedoratleastabiopsy.Isthereanychanceofyoudoinganything?MrBlack,TmnowabletogiveyoutheresultoftheWell,thingsareprettybusyatthemomentbutifyoutestsonthelump(hatweremovedfromyounose.ItsendherinIwillhavealookatitandtrytoreassureturnedouttobearodentulcer.Ifithadbeenleft,ither.IfsheistheworryingkindImightbeabletofitwouldcertainlyhavecontinuedtogrow,butwouldherininacoupleofmonths.nothavespreadtoinvolveotherpartsofthebody.ItThatwouldbefine.Thanksalot.appearstohavebeencompletelyremovedbutwe'llNotatall.Keepintouch.needtofollowyouupattheclinic.Ofcourse,thanksagain.Goodbye.Bye.Mr.Evans,Wenowhavetheresultofthehistologyonthechangingmolethatweremovedfromyouarm.108GENITALHERPESUnfortunately»itisatypeofmolethatisnowGenitalandurineinfectiongrowingandiscalledamelanoma,thisisaseriousGenitalherpesconditionandthereisachanceitwouldspreadtoinvolveotherpartsofthebody.ThebestguidetotheIhaveaburningpaininmygenitalarea,andit'slikelihoodofitspreadingisthethicknesswhichinuncomfortableformetopasswater.yourcasewasonepointfivemillimeter.ThisisveryHowlonghaveyouhadthis?thinandthereisthereforeonlyaverysmallchanceTwoorthreedays.thatitwillspread.ItwillbenecessarytoperformHaveyounoticedagenitaldischarge,MissJohns?anothersmalloperationjusttoensurethatit'sbeenNo.completelyremoved.Afterthatwe'llcontinuetoseeDoyoumindifIexamineyouandtakesomeswabsyouregularlyforatleastfiveyears.Althoughit'stoseewhatinfectionyouhave.Couldyoupleaseseriousconditionit'sgoodthatitwasremovedundressandsituponthecouchforme,I'mgoingtobeforeithadgrownanyfurther.Doyouhaveanytakeaswabfromtheareawhichispainful.ThismayquestionsthatIcananswer?bealittleuncomfortable....Ithinkthatyoumayhaveaherpesinfection,andyouwouldbenefitfrom107REFERRALgettingsometabletstohelpthisgoawayalittlereferralquicker.Ithinkthebestthingforyoutotakewouldbeatabletcalledacyclovir.Takeonetabletthat'sHelloJohn.Howareyou?twohundredmilligramfivetimesdailyforfivedays.HelloDavid.Tmfine,howaboutyou?You'llfindthatyouarestillinsomediscomfortforFinethanks.Iwantedtotellyouaboutoneofmythenexttwoorthreedaysbutthiswillsettledown,patientsI'dlikeyoutosee.andthereisnothingtoworryabout.IwouldalsoRight,fireaway.suggestthatyoutakesomepainkillersuchasShehasamoleonherrightcalf.Sheisthirtyeightparacetamol,twotabletseverythreehoursfortheandsaysit'sbeenthereforyears.pain,andyoualsofindithelpfultotakeasaltwaterDoesn'tknowhowlong?bathtwiceadayuntilthisclearsupcompletely.No,butshe'snoticedthatoverthepastfewmonthsWeMlseeyouagainattheclinicnextweekandbyit'sdevelopedacrustyedgetoit.thattimeallyoursymptomswillhaveimproved.Hasitgotanybigger?Beforeyouleavetheclinic,IwouldbegratefulifNo,apparentlynot.WhenIhadagoodlookatitIyouwouldgivemeaspecimenofurineassometimes54
55withaherpesinfectionyoucanhavedifficultyinasthisinfectionissexuallytransmitted.Itwillbepassingurine.Ifinthenextweekyouhaveanyimportantforustoseeandtreatyourregularsexualproblem,youcan,ofcourse,contacttheclinicandpartner.Youneedtoreturntotheclinicinaboutonewe'llseeyousoonthanarranged.totwoweeks'timesothatwecancheckthatthisinfectionhasclearedup,andalsogiveyoutheresults109VAGINALINFECTIONSANDofyourothertests.DISCHARGEWhileyou'reattheclinicyouwillbeaskedtospeakVaginalinfectionstothedepartmentalhealthadvisororcontacttracer.DischargeHewillgiveyousomeinformationaboutthisinfection,andIwouldrecommendthatyoubringinTrichomonasvaginalis?:ឋ▢⍝C▢⍝D?:yourboyfriendforhischeck-up.BeforeyouleaveFlagylE?ᮣᑴᑺḄᖪGHtheclinicyou'llalsobeaskedtoprovideaspecimenslideIJᱏJᱏLMᱏofurinefortestingandalsotakearoutinebloodtestforsyphilis.ThisisaroutinebloodtestwhichisdoneFvenoticedagreen,smellydischargefrommyandperformedoneverybodywhoattendstheclinic.vagina.It'salsopainfulwhenIpasswater.Howlonghaveyouhadthedischarge?1leakfromthepenis.It'shurtingmetopassurine.Twoweeks.Howlonghasthisbeenhappening?Haveyounoticedanitchingdownbelow?Afortnight,/twoweeks.No.Haveyouhadaregularsexualpartner?Doyouhavearegularsexualpartner?No.Yes,IhaveapartnerwhoIhavebeenwithforsixWhendidyoulasthavesexualcontactwithapartner?months.Lastweek.Whenwasthelasttimeyouhadsexualintercourse?Hasyourpartnerhadanyproblemslikethis?ThelasttimeIhadintercoursewasaweekago.Theyhaven'tgot/don'thave/anysymptoms.Doesyourpartnerhaveanyofthesesymptoms?Ineedtotakesomeswabsfromtheendofyourpenis.No,mypartner'sbeenquitewellwithnoproblem..Theremaybealittleuncomfortable.PmgoingtoI'dliketoexamineyouandtodothisrilneedtoasksendthemofftobetestedforinfectionsuchasyoutoundressandgetupontothecouch.TmgoinggononhoeaandChlamydiawhichcanbepassedtototakesomeroutineswabslookingforinfectionsyouthroughsexualcontactwithsomebodywiththesuchasgonorrhoeaandChlamydia.Vmgoingfirsttoinfection.SomeoftheslidesthatI'lltakefromyoutakesomeswabsfromwhereyoupasswaterandthentodaywellbelookedatintheclinic,andformtheseFilinsertaspeculumandhavealookatyourcervixFildecidewhetheryourequiretreatmentornot...andtheinsideofyouvagina.We'HtakesomeswabsfromtheslidethatFvejustlookedat,youseemtobothfromyourcervixandyouvaginatolookforhaveaninfectionwhichyouprobablyacquiredsignsofinfection.Filthentakeaswabfromtheareathroughhavingsexualcontact.Ithereforethinkit'saroundyourbackpassage...Tvehadalookatoneofnecessarythatwegiveyousomeantibiotic.Tmyourinitialtestsunderthemicroscopeandyou'vegoingtoprescribesomeoxytetracycline250mggotaninfectioncalledTrichomonasvaginalisorTVtakenfourtimesadayforsevendays.Iwouldadvisewhichisthecauseofyourvaginaldischarge.ThisisyounottotakeanyalcoholwhileyouareontheseeasilytreatedwithaformofantibioticscalledFlagylantibiotics,andtoavoidtakingtheantibioticswithmetronidazole.Youhavetotakeonetablet200mg3milkproductsasthiscanaffecttheirabsorption.timesadayforoneweek.Duringthattimeit'sWellseeyouagainattheclinicintwoweeks'timeimportantthatyouavoidalcoholandsexualcontactbywhichtimeyoursymptomsshouldhavesettled.55
56Whenyoureturntotheclinic,weshouldhavethetwoweeks'timeforfurthertreatment,andbythatresultsoftheculturesthatIhavedonetodaywhichtimetheresultsoftheteststhatIhavedonewillalsoshouldbebackbythenandtheywillhopefullybeback.Wouldyouliketoaskmeanyquestionsindicatewhatinfectionyouhave.beforeIask.youtoseethehealthadviser?DIalsogetyoutospeaktooneofthecontacttracersDoctor,IwonderhowIgotthewarts.whowillgiveyousomeinformationaboutsexuallyYou'vebeenexposedtothegenitalwartsvirustransmittedinfectionandhowyoucanpreventfromthroughsexualcontactwithsomebodywhoeitherthem.Beforeyouleavetheclinic,couldyoupleasehasgenitalwartsorthevirusinhisskinandthegivemeaspecimenofurinesothatIcantestitforgenitalarea.Unfortunately,Icannottellyouhowanysignsofinfection.Iwillalsoneedtotakeabloodlongyou'vehadthevirusinyourskinorwhoyousamplefromyouwhichwillbetestedforsyphiliscouldcaughtitfrom.Asitdoesnothavetobeyourwhichisaroutinebloodteatwedonoeverybodythatpresentpartnerbutcould'vebeenfromapartnerattendstheclinic.severalyearsago.Don'tbedisheartened.ThewartsThankyou.willdisappearedwithtreatment,butunfortunately,Ican'tgiveyouanyguaranteethattheywillnotreturn.110GENITALWARTSWartsareaverycommonproblemandIdon'tthinkGenitalwartsthereisanythingtoworryabout.WhileyouhavetheFvenoticedtheselumpsdownbelow,afriendsaidwarts,Iwouldsuggestthatyouuseabarriermethodtheymightbewarts.ofcontraceptionduringintercourse,suchasaHowlonghaveyouhadthewarts?condomanddon'thavegenitalcontactwithoutthis.Ifirstnoticedthemsixmonthsago.Aretheyitchy?IllHIVYes,especiallyatnight.HIVHaveyounoticedanyvaginaldischarge?FvejusttoldyouthatyouhavegotaChlamydiaNo,doctor,Ihaven't.infection,ChlamydiaisacommonsexuallyI'dliketoexamineyou,andIwouldbegratefuliftransmitteddisease.Wealsoknowthatsexuallyyoucouldpossiblyundressandsituponthecouchtransmitteddiseasestendtogotogether.Fortheseforme.I'mgoingtodosomeroutineteststomakereasonIthinkyoushouldconsidereitherbeforeyousurethatyoudon'thaveanyotherinfectionalongleavetheclinicoratafuturedatehavingabloodtestwiththewarts.Thesewilllookfortheinfectionstocheckwhetherornotyou'vegotantibodiestothesuchasgonorrhoeaandChlamydiaandvaginalIVvirus.ThisdoesnottelluswhetheryouhavegotinfectionssuchasTVorcandidaetc.OnceFveseenAIDS,butitdoestelluswhetherornotyouarethewartsI'lldecidehowtheyarebesttreated.Ialsoinfectedwiththevirusandaswellasbeingadangerthinkit'sveryimportantthatyourpartneralsotoyourhealth,obviously,you'realsosexuallyattendstomakesurethathedoesn'talsohavegenitalinfectioustootherpeople,soyoumaythinkaboutwarts...Wartscanbetreatedbyfreezingthemwithhavingthisbloodtestinordertoprotectfuturesexualliquidnitrogen,butIthinkthebestwaytotreatyourpartners.However,thistestisnotcompulsoryanditwartswouldbetoputsomepodophyllumpaintonisonlydonewithyourcooperationafteryou'vethem.Youwillberequiredtowashthepaintoffafterthoughtthroughthevariousargumentsforandsixhoursbecauseifyouleavethisonforlongerthisagainsthavingthetest.Ifyoudohavethetestitisamaycausesomediscomfort.Filaskyoutogoandsimplebloodtestandtheresultwillbeavailableforspeaktooneofhealthadvisers,who'llgiveyousomeyouifyoucomebacktotheclinicinoneweek'stime.informationongenitalwartsandhowyou'veThisresultisnotgivenoverthephoneandyoumustacquiredthem.You'llneedtoreturntotheclinicinattendinperson.Ifyouareunluckyenoughtobe56
57HIVpositive,we'HgiveyouallthesupportandMyeyesarewateryandmyeyelidssticktogetherininformationwhichisnecessarytocometotermswiththemorning.thisinfection.I'mworriedaboutmyeyes.Isometimesseeflashinglights.Iseemtohaveaproblemwithmyeyesight.It*sasif112ADVICETOAHOMOSEXUALMANagraycurtainisbeingpulledacrossmyface.AdvicetoahomosexualmanI'mhavingseverepaininoneeyeandwhenIlookatalightthereseemstobeastrangerainbowhaloFvejusttoldyouthatyouhavegonorrheawhichisroundit.anSTinfection.Unfortunately,wealsoknowthatDoctor,Iseetwoofeverything.gaymenarepronetootherinfectionparticularlyviralIkeepgettingasharppaininmyeye.hepatitis,hepatitisBandCandalsoHIV.IwouldMyeyefeelsdryandgritty.adviseyoutohavethesetests.However,wellonlyFvenoticedthatmyeyeballismoreprominent.performthemwithyouragreementandafterwe'vediscussedtheimplicationfully.Ifyoualsoturnoutto114REFRACTIVEERRORSbenegativeforhepatitisB,thenforyourfutureRefractiveerrorsprotectionwecanofferyouacourseofhepatitisBvaccinationwhichwillprotectyoufromfutureThereasonyourvisionisblurredisbecauseyouareinfectionformthevirus.Particularlyifyouhavelong-sighted/far-sighted/-thisiscalledhyperopiainboosterinjectionseveryfewyears.Beforeyouleavemedicalterms.Thisisnotapathologicalconditiontheclinic,you'llalsobeinterviewedbyahealthbutavariantofnormal.Youhavebeenbornwithaadviserwhowillinstructyouinthetechniquesofshorterthanaveragelengtheyeballandwecansafesex,suchastheuseofcondoms,sothatyouareovercomethisproblembyprescribingglassesforlesslikelyinthefuturetocontractoneofthesesdistance-outsidespecs(=spectacles)-andforinfections.reading.Willmyvisionbecomeworsewithtime?Intheabsenceofanyotherproblemstheglasses113MOSTCOMMONCOMPLAINTSshouldcorrecttheblurredvisioncompletelyandtheOphthalmologyvisionshouldnotdeteriorateovertime.MostcommoncomplaintsHowdotheglasseswork?Normallyapersonwithlong-sightednesscanIfeelmyvision'sdeteriorated.Idon'tseeclearlyanycompensateforthesmalleyebyincreasingthemore.refractivepoweroftheirownlensinsidetheeyeFmnotseeingaswellasIusedto.Everythingiswhichhastheeffectoffocusingthelightraysontheblurred.Thingsaren'tsharpanymore.retina,theseeinglayeroftheeyeandobtainingaFvenoticedmyeyegraduallybecomingabitredandsharpfocusoftheobjecttheyarelookingat.painfulrecently.Myvisionhasbecomeblurred.ThingsseemcloudyThismeansthatyouareshort-sighted/near-sighted/.andmisty.Youhaveaproblemfocusingondistantobjects.YouIhaverealdifficultydrivingbecauseoftheglarehavetobeclosertoanobjecttoseeitwell.Thisisfromheadlightsorevenfromthesunreflectedonthebecausetheaveragelengthofyoureyeballislongerroad.thannormal.ThismeanstheimageisformedbeforeSometimesIgetblackspecksfloatinginfrontofmyyourretina.Toformtheimageontheretinayouneedeyes.towearcorrectiveglasses.Theremayberetinal57
58complicationwithageing.willopenupthepupilssowecanseeintothebackoftheeyemoresharply.ThedropswilljustsmartforaInyourconditionyoumayseeblurredobjectssecondortwoandittakestenminutesforthedropsbecomeofaprobleminyourcornea.Thismeansthattoworksoifyoujusttakeaseatoutside.Tilcallyouthecurveonyourcornealsurfaceisnotthesamebackintenminutes.Thedropsusuallylastabout4oreverywhere.Thiscandistortimagesthatyousee.5hoursorso,sodon'tbeworried.YourvisionwillThat'swhyyouneedtowearglasses.beblurredforawhile,andyouwon'tbeabletoreaduntilthedropswearoff.ThepupiloftheeyewillbeAsyougetolder,usuallyafteraboutforty,theabilitymuchbiggerbutitwillbenormalbythetimeyouofthelenstochangeitsshape,whichwecallthewakeuptomorrowmorning.powerofaccommodationdecreases,andthepersonfirstofallhasdifficultyreading.Laterthedistance4,visionisalsoaffected.Wejusthavetocheckthepressureintheeye.Wehaveasmalldevicethattouchesthefrontoftheeye.115EYETESTSDon'tbeworried.Youwon'tfeelanythingbecauseEyetestsFilputsomeanaestheticdropsinfirst.It*simportantnottosqueezestheeyesortoblink.1,Iwillcoveryourlefteyenow.lookatthecharton5,thewall.JuststartreadingthechartfromthetopFmcheckingtherightvisualfield.Coveroverthedowntothebottom.That'sfine.Wouldyoucoverlefteyewithyourfingers.Sitfacingmeandlookyourrighteyenowandjustreadtheletterswithyourstraightatmynose.I'mgoingloholdoutmyhandtolefteye.thesideandwigglemyfingers.Keeplookingstraightatmynose.Don'ttakeyoureyesoffmynose.TellEdjustlikeyoutotakethispinholeinyourrightmewhenyoucanseemywigglingfingers.hand,coveroveryourlefteye,holdthepinholeuptoyourrighteye.Doyouseethelightthroughthe6,pinhole.Canyouseethenumberintheplate?Ifyoucan,tellNo.mewhatnumberitis?(ifso,canyoutellmewhatitJustmovethepinholeslightlyoveryourheaduntilis?)youfirstseethelight.Yes.116CHALAZION,HORDEOLUM/STY(E)Doyouseealetterinthemiddleofthelight?chalazion,hordeolum/styEnvelopeIcan'tmakealetterout.I'venoticeasmalllumponmyeyelidwhichhas2,becomesoreandred.Ithinkit'sasty(e).PutyourchinontheresthereandyourforeheadupAha.Letmehavealook...no,thatisn'tastye.Aagainstthebar.Nowthatyouaresittingcomfortably,styeisalwaysontheedgeoftheeyelidandit'sancanyouseemyleftear?Alwayskeepyoureyefixedinfectionattherootofaneyelashduetoaonmyear.Don'ttakeyoureyeoffmyear.Lookchronicallyinflamedgland.Thisisfurtherupthestraightahead.Nowlookup.Nowlookdown.eyelidandit'swhatiscalledachalazion.It'scausedbytheoilsecretionswhichhavebeentrapped.We'll3,putonapatchtobringthechalaziontoaheadandIjustwanttopop/put/somedropsintoyoureyesthatthenwe'llputonsomelocalanaesthetictofreezeit58
59andthenmakeasmallcutintheinsideoftheeyelidstillcanrecurandmayevencomebackintheotherandscrapethecontentsout.We'llalsogiveyouaneye.eyepatchtoputontheaffectedeye.You,llhavetousesomeointmentbeforeyouputthepatchon.119CATARACTCataract117CORNEALABRASIONCornealabrasionIamhavingaproblemwithmyeyes.Myvision'sYouhaveascratchinthefrontofyoureye.Whathasbeenverypoorlately.It'sveryblurred,andFvegothappenedisthattheepitheliumofthecornea,whichtohaveabrightlighttoreadanythingthesedays.is“theskininfrontoftheeye“hasbeeninjuredsoitWiththevisionthatyou'vegot,areyouabletodojustfeelsasthoughthereissomethinginyoureye.verythings,orisitholdingyouback?IsyourvisionWhenthelocalanaestheticwearsoff,therewillstillinterferingwithyourlifestyle?beafeelingthatthereissomethinginyoureye.ButI'mnotsure,doctor.don'tworriedthereisnothingintherenow,itisonlyIsee.Areyoustillhavingtroublewithyourdiabetes?thescratchyoucanfeel.It'lltakeabout24hourstillYes,butwe'regraduallygettingitundercontrol.thefeelingdisappears.IwantyoutowearthispatchIsee.Thenlet'sdoanexaminationonyoureyes....onyoureyeand1wantyoutokeepitonfor24hours.Theproblemisthatyouhaveacataract.It'sanThenyoucantakethepatchoff.....Iwantyoutoputopacityofthelensoftheeye.It'softenassociatedmoreointmentonandputthebandagebackforwithdiabetesorwithgettingolder.Youhavenothinganother24hours.Onceyouhavetakenthepatchoff,toloseinwaitingfortheoperation.ButIwouldn'lthenusetheointment.Itischloromycin.UseitthreeputoffthedecisionifIwereyoubecausethesoonertimesadayforaboutthreedaysandifyoureyeyouhaveyouroperationdone,thesooneryou'llbedoesn'tgocompletelybacktonormal,comebackabletogetbackyournormalsight.Youdohaveanandseeus.earlydegreeofcataract.Cataractisverycommon.Almosteveryoneovertheageof50or60hasitand118IRITISit'salmostnormaltohavesomedegreeofcataractIritisthen.It*sjusttheamountofcataract.Ifthecataractinterfereswithyourabilitytoenjoyyourlife,thenweWearenotsurewhatexactlycausesiritis?Itcouldwouldconsideroperating.becausebyoneoftheseveralthings,soweneedtoThisistheprocedureofcataractsurgery.sendyouforafewteststoseeifwecangettotheWewillneedtodoanartificialintraocularlensrootoftheproblem.TherearetwotypesofdropsIimplantation.Beforetheoperation,wewillmeasurewanttogiveyou.Oneoftheseisasteroiddrop,youreyetodecideonthelensthatyouneed.Thisissteroidsjusttendtosuppressinflammationandmaketheverylatesttechniqueandwehavehadsometheeyelessredandirritable.Thisdoesn'tcuretheexcellentresultsforit.Whatwe'lldoistogiveyouaunderlyingproblem.Theotherdropisthedilatedrop,localanestheticandsomethingtohelpyourelax,sothesearejustgoingtomakeyoureyesfeelmoreyou'llbeawakeduringtheoperation.Butyouwon'tcomfortableanditwilldilatepupilandhelptohealbeabletoseeorfeelanything.Thenwemakeasmalltheeye.Youmustkeepupwiththedropssinceitcutonthesurfaceofyoureyeandremovethegreywilltakeseveralweekstohealthecondition.Don'tlens.Ifallgoeswell,weputinthelensimplant.beworriedifyouseethatyourpupilisbig,Aftertheoperationyoucancarryonwithlifeasparticularlyifyourversionisblurredforreading;thatusualexceptforstrenuousactivities.You'llhavetoisknownsideeffectofthedropssodon'tbeworrieduseeyedropsaswellandcomebacktoletuscheckifyougetthat....Althoughwe'vecuredyouriritis,itonhowtheeyeishealing.6weeksafterthe59
60operation,we'llprescribesomeglassesforyou.Ican'tguaranteeputtingalensimplantin,butnine121RETINALDETACHMENTtimesoutoftenwehavenoproblemsgettingalensRetinaldetachmentimplantin.Andifwedidn'tputthelensimplantin,there*sstillsomethingelsewecando.WecaneitherIdescribeitlikeanoldfootball,yousee.Theeyeballputacontactlensonorwecangiveyouaplus10(+islikeanoldleatherfootball.Theleatheristheback10)dioptrelenstocorrectyourvisionorconsideroftheeyeandtheretinaisthebladderofthefootball.puttingalensofplantintheeyeatalaterdate.Normallythebladderishardup/directly/againstthefootball,theretinaisheldcloselytothebackofthe120GLAUCOMAeyetogether.ThereisnormallyfluidinsidetheGlaucomabladderandwhathappensinaretinaldetachmentisthatyouhaveasmalltearinthebladderandthefluidGlaucomaisadangerousconditionbecauseitcomesoutfromthemiddleofthefootballthroughdoesn'tgiveyouanysymptomsintime.There'snothetearandthenfloatsthebladder,theretinatearspain,noredness.Butifthepressureintheeyeisawayfromthebackoftheeye,thefootball.Anduncontrolleditwellcontinuetodamagethenervealwhatwehavetodointheoperationistofindthetear,thebackoftheeyeandreducethewidthofyoursealitwithafreezingtechniquetocreateascarversion.Thatiswhyyoumustcarryonwith/keeparounditandthenasthefluidisabsorbed,theretinausing/thesedrops.Youmustcomebacktothewillbecomeflatupagainsttheeyeagain.Therearehospitalonaregularbasisjusttohavethepressuretwoaspectsofvision,centralvisionandthewidthofchecked.Evenifthepressureishigh,you,llhavenoyour/peripheral/vision.Centralvisionisthevisionsymptoms.Oneofthewaysofthemonitoringtheyouuse99percentofthetime,butitonlyaccountsconditionistocometoout-patientregularly.Herefor1percentoftheeye.Andwhenthisareabecomeswe'Hchecktheeyepressure,visualacuity,opticdetachedordamaged,theneventhoughit'sreplacednerveheadanddoaperimetryexamination.It'srightwayitsometimesdoesn'tworkaswell.Sotheimportanttousethedrops.Withglaucomathere'snochancesareyourreadingandwritingvisionwon'tbewaywecangetbackthevisionthat'sbeenlost.It'saasgoodasit'sbeen,eveniftheoperationistotallymatterofretainingwhatvisionisleft.successful.122MACULARDEGENERATIONIcanseethatyoureyesaresoreandredandyourMaculardegenerationvisionisblurred.Thisisbecauseyouarehavingaglaucomaattackatthemoment.ThepressureisveryI'mhavingproblemswithmyeyes.Myvisionseemshighinsideyoureye.Wereallyhavetoadmityoutotobegettingblurred.Thisiscausingproblemswithhospitaltogetthepressuredown.Hopefullywe'llbemyreading.It?sstrangebecauseIcanseequitewellabletodothiswithdropsandsometablets.YouareatthesidesbutnotwhenIlookstraightatsomething,almostcertaintorequirealaseroperationtogetthethereseemstobeablurredpatchinthemiddle.pressureundercontrolafterwards.It'snotbeyondtheboundsofpossibilitythatyou'llneedanoperationYou'vegotsomechangesatthebackoftheeyedueratherthanalasertreatmentontheothereyeaswelltoagingandwe'llneedtodecidewhetherit'sjusttopreventthesamethingfromhappeningagain.treatableornot.ThereisnochanceofgoingblindIt'sbecauseofanunderlyingtendencyfortheotherwiththis.Theagingchangeofthemaculaaffectseyetobeatriskandbecausebotheyestendtobethecentralvision,that'syourreadingandwritingvision,same.Thatisthereasonitneedstreatment.butyoustillhaveperipheralvision,thisisyournavigatingvision.You'llnevereverlossthiswith60
61maculardegeneration,soyou'llneverevergoblind.I'vegotaflashburn.You'llbeabletoliveareasonablynormallife.Iwashammeringsomesheetmetal,Ithinkasmallpieceofmetalshotintomyeye.maculardegenerationNᦿOឋIwasgrindinganengineblockandasliverofmetalnevereverPQRQflewintomyeye.Iwasfryingsomeeggsandsomehotfatspattered123RETROBULBARNEURITISintomyeye.Retrobulbarneuritis125DIPLOPIA,STRABISMUSThenerveatthebackoftheeyerelaysinformationDiplopia,strabismusbacktothebrainandthatiswhyyouseethings.Whafshappenedisyou'vehadaninflammationofIseetwoofeverything,doctor.theneveratthebackoftheeye.ThisnormallygetsNowrdlikeyoutolookinanumberofthedirection.betteronitsownsothereisnoreallyactivetreatmentFollowmyfingerwithyoureyes,lookup,lookdown,wecangiveyoutoimproveit.Theretinarecoverslookleft,lookright.Doyouseeoneblurredimage,andinthegreatmajorityofpeoplethevisioncomesordoyouseetwoseparateimages?backtonormaloralmostcompletelytonormal.Two.ThereisachanceoftheproblemrecurringandI'dbeAreyousureaboutthat?happytoseeyouanytimeifthisshouldhappen.AreYes,IstillseetwoimageswhenIlooktotheleft.thereanyotherquestionsyouwanttoaskme?Coveroneeye,doyoustillseetwo,ordoyouseeNotreally,doctor.one?DoyouhaveanydizzinessortinglingorweaknessorJustone.unsteadiness?Covertheother.Doyouseetwoimagesnow?Whyareyouaskingmethesetypesofquestions?Yes.Becausethistypesinflammationcanaffectnervesalloverthebodynotjustintheeye.Doctor,TmwomedaboutSusans'eye.She'sgotaDoyouthinkI'vegotmultiplesclerosis,doctor?badsquint.Well,thereisanassociationwithmultiplesclerosisRight,letmehavealookatit....Yes,she'sgotasothereisapossibilitythatthismayhappenagaindefinitesquintinthelefteye.Therearetwothingsandmayturnouttobemultiplesclerosis.Howeverhere_thecosmeticappearanceandtheriskofthereareothercausesanditmaywellbeasimpleamblyopia.Thedifficultwithasquintisthatforthepost-viraltypeofthing.Othercausesforthisvisiontodevelopnormallybotheyesmustseeaproblemarenicotineandalcohol.Butyouareright,sharpimageandtheymustbothbepointinginthewecouldn'tsayforsurethatthiswouldn'thappenrightdirection.Ifoneeyeisn'tseeingsharply,orifitagain.isnotpointingintherightdirectionandthenthebraintendstoignoretheimagefromthateye.Ifthat124EYEINJURIESiscasethentheconnectionsneverdevelopintheEyeinjuriesbrainandthateyethenbecomeswhatwecallalazyeye.ThisisthereasonwhywehavetokeepthepatchFvegotsomethinginmyeye,doctor.onthegoodeye.LittleSusanwillwanttokeepI'vebeenpokedintheeye.takingitoff,butwemustmakesureshekeepsitonMysonscratchedmyeye.tomakethelazyeyeworkandbuildupthoseIsplashedsomeacidinmyeye.connectiontothebrain,IfyourvisionisasgoodasIhadsomethingsprayedinmyeye.you'regoingtoget,it'spurelyamatterofcosmetic61
62appearance,HowisSusangettingon/along/atthedrasticbuteyetumoursbehavedifferentlyfromotherschool?Doesshegetteasedorbullied?tumoursinthebodysothere'sahighchancethatYes,she'ssometimesveryunhappywhenshecomesoncewetaketheeyeoutthatwillbetheendofthehome.rumourandthecancerwillberemovedtotally.SoThat'sapity.However,it'sonlyasmallangleofaalthoughyou'llhavelostyoureyeyou'llhaveasquintandtheriskofsurgeryreallyoutweighandnormallifespananditwon'laffectyourgeneralpotentialbenefits.Squintsurgeryismuchmoreofanhealth.artthanascienceandwecan'tguaranteegettingtheeyesabsolutelystraightalthoughwealwaystryourAftertheoperationyouwillreceiveinformationbest.Soiftheanglesareverysmall,Iwouldadviseregardingblindregistration.younottohavetheoperationbecausewecouldn'tguaranteethatwe'regoingtomaketheappearanceAlthoughyouaretechnicallyqualifiedforblindthatmuchbetter.registration,thisdoesnotactuallymeanthatyouaretotallyblind,it'sjustameasurementofyourpoor126TUMOUROFTHEEYE,BLINDvisionandyourvisionispoorenoughtoactuallyREGISTRATIONqualifyforblindregistration.tumouroftheeye,blindregistration127TYPICALSYMPTOMSYouhaveatumouroforbitandweneedtocheckTypicalsymptomsuponexactlywhatitissowewillperformabiopsy.Isuspectittobeacancer.TheonlywayofmakingAsureofthistoactuallysendittothehistologydepartment.TheretheywilllookatitunderaIhaveabadheadache.microscopetodeterminethediagnosis...Ihaveathrobbingheadache.Ifeeldeadtired.There'sasmalltumourontheeyelidwhichisIhavepoorbalance.actuallyabasaloma,butthat'snotallbadnewsMymemoryisgoing.becausewe'llbeabletoremoethatforyouandIhaveaterriblememory.there'sa95%chancethatitwon'tgrowbackagain.Ihaveadifficultyconcentrating.Wewillremovethewholetumoursodon'tworry.Ihaveadoublevision.Althoughyou'vegotamelanomainyoueye,it'sstillIhaveadifficultyfocusing.inanearlystagesowe'lltreatitwithlasertherapy.Myvisionseemsblurred.It'snotaffectingtheeyeatthemomentandIhavezig-zaglinesinfrontofmyeyes.hopefullywe'HbeabletotreatitwithoutaffectingMyeyeshurtinbrightlight.theeyesight.LasertherapyisveryeffectiveanditishighlyunlikelythattherewillveanyrecurrenceofIhavedifficultyspeaking.thecancer.Icannotgetthewordsoutclearly.Ihavedifficultyswallowing.FmsorrytohavetotellyouthatyoudohaveaneyeFoodseemstostickinmythroat.tumourandweUIhavetodosomethingaboutit.I'mafraidthatIt'smelanomaoftheeye.It'sinanBadvancedstagesoitisverylikelythatwewillhaveMyneckfeelsstiff.toremovetheeyeitself.IknowthatsoundsveryMyneckclicks.62
63Myback'sgone(inspasm).Myhandsareshaky.DIhavenostrengthinmyfingers.1wassittingwatchingTVwhenmyarmssuddenlyIcan'tpickupacupanymore.becamenumbandheavy.MywifesaidthatmyfaceMyco-ordinationispoor,especiallyismyarms.twistedtooneside.ItcameverysuddenlyjustoutofMyarmsfeelweak.theblue.IthoughtIwashavingastroke.ItseemedtoIfeelpinsandneedlesinmyhands.getbetterbyitselfafterabouthalfanhour.Mylegdrags.ItendtocatchmyfootwhenIwalk.EMyfootisnumb.Fvegotaproblemwithmyback.,IwasliftingaMyfoothasdropped.heavyboxandIfeltsomethinggiveinmyback.ItMylegfeelsstiff.wassuddenlysharppain,likelighteninggoingdownBothmylegsfeelstiff.thebackofmyleg.ThepainwentdownallthewayIcan'tfeelmyfeet.tomyheal.Itwaslikeaflashjustforamoment.Mytoesfeelnumb.Sincethen,Fvehadalotofpainlowdownintheback.CblackoutS(ឋTUVᜫdrag(YZ[)]^_Ihavedifficultypassingwater.᠒abIfinditdifficultgoingtothetoilet.IfindIgotothetoiletveryfrequently.128NAMESOFINSTRUMENTSUSEDINIhavesuddenblackouts.NEUROLOGICALEXAMINATIONIlossconsciousnesswithoutwarning.NameofinstrumentSomeonesaidthatIhadaconvulsion.SomeonesaidthatIhadafit.Visualacuitychart-usedintestingvisualacuitySomeonesaidthatIhadaseizure.Ophthalmoscope-tolookintothebackoftheeye.Auriscope-tolookintoears.Myarmtwitchesfornoreason.Tonguedepressor-toexaminethetongueandtheMyhandjerkswithoutwarning.backofthemouth.Iseemtogovacant/blank/forashortperiodoftime.Orangestick-(don'tknowwhatitis)Wispofcottonwool--toexaminewithalighttoughMymusclesfeelstiff.Sterileneurologicalpin---totestskinsensationMymusclesaresore.Tuningfork.——totestvibrationsenseMymusclesarepainful.Tendonhammer-Stoelicitdeeptendonreflexes.I'mlosingweight.Patellarhammer-totestpalatalsensationMymusclesaregettingthin.Fmachingallover.129ASSESSMENTOFHIGHERMENTALFUNCTIONSMyfacehasgonelop-sided./1can'tmoveonesideAssessmentofhighermentalfunctionofmyface.Myfacehastwistedtooneside,/halfofmyfaceisCanyoutellmeyournameandaddress?I'mgoingtoparalyzed.askyousomesimplequestionstoassesshowgoodMyfaceseemstohavegotweakononeside.yourconcentrationis.CanyoutellmewhatdayofMymouthisdrooping.theweekitistoday?Whatmontharewein?What63
64yearisit?Approximatelywhattimeofdayisitat2.Now1wanttoexaminethestrengthinthemusclesthatmoment?Canyoutellmeanythingthatisgoingofyourface.Screw/close/youreyesupverytightly,oninthenewsatpresent?WhatisnamethePrimedon'tletmeopenthem.Nowpurse/close/yourlipsMinister?I'mgoingtogiveyouanimaginarynametogetherverytightly,stopmefromopeningthem,andaddress.Iwantyoutorememberthenameofblowyourcheeksoutlikethis.address,andafter5minutesFilaskyoutorepeatthe3.NowI'mgoingtotestyourhearing.Tellmeifyounameofaddresstome.NowI'dliketoassesshowcanhearwhatI'mwhisperingintoeachearinturn.clearyouspeechis.Saysomewordsfbrme.StartbyTwentynine,fortyfive.sayingthedaysoftheworkstartingwithMonday.4.Now1wanttoexaminethemusclesofthebackofNowI'mgoingtoaskyoutosaysomemoredifficultyourmouth.Openyourmouthwideandsayoh.things.Sayafterme“babyhippopotamus","British5.Tmgoingtotestthefeelingatthebackofyourconstitution”.Now,I'mgoingtoexamineyourmouth,tellmeifyoufeelagentletouchofawoodenunderstandingofthewordsthatIsaytoyou.Liftstick.yourrighthandintheair.Touchyourrightearwith6.Now,openyourmouthwideagainandstickyourthelittlefingerofyourlefthand.NowFdliketoseetongueout,wiggleyourtonguequicklyfromsidetohowyouwalk.Iwantyoutostandupandwalktotheside.othersideoftheroom,thenturnaroundandcome7.Finally,shrugyourshouldersagainstmeandturnbacktome.yourheadtoonesideandthenturnittotheothersidesothatIcanseethestrengthofthemusclein130EXAMINATIONOFTHECRANIALyouneck.NERVESExaminationofthecranialnerves131EXAMINATIONOFTHEARMSExaminationofthearms1,Coveronenostrilandsmellthissubstance,tellmewhatitsmellslike.Nowwe'removingontoexamineyourarmsand2,I'dliketocheckyourversion,readthechartinlegsneurologically.frontofyou,please.Startingfromabouthere.Startbyputtingbotharmsoutintheairinfrontof3,I'mgoingtoassesswhatyoucanseeoutoftheyouandshutyoureyes.HoldthearmsstillwhileIcomerofyoureye,lookatthemiddleofmyfaceandlookatthem.NowwiggleyourfingersasthoughyoupointatmyfingerwhenIwiggleit.wereplayingthepiano.Nowletmeassessthe4,NowI'mgoingtoshinealightinyoureyetolookco-ordinationinyourarms.Openyoureyes,makeaatthereactionofthepupil.Keeplookingstraightpointerbystretchingoutyourindexfinger.Nowahead.KeeplookingstraightaheadwhileIshineatouchmyfingerandthentouchyournose.Golightinthebackofyoureyetoexaminetheretina.betweenmyfingerandyournosewithyourfingerTryandkeeplookingforwardatthewallbehindme.veryquickly.Nowtrythisontheotherside.tryandignorethelight.5,NowI'mgoingtoassessthemovementsofyourNowFmgoingtoassessthestrengthinthemuscleseyes.Holdyourheadstillandfollowmyfingerjustofyourarms.bymoveyoureyes.1.Stickyourarmsoutonbothsidesandshowmethestrengthofyourshouldermuscles.1.NowI'mgoingtoassessthefeelingonyourface.2.Nowpulltheelbowsdowntowardsyoursides.Pmgoingtouchtheskinonyourfaceverylightly3.Nowtestingeacharminturn,makeafistandpullwithsomecottonwool.Say"yes"whenItouchyourthefistuptowardsyourshoulderwhileItrytostopfaceandkeepyoureyesclosed.you.64
654.NowstraightenyourarmsoutattheelbowwhileItrytostopyou.Dothatagainontheotherside.132EXAMINATIONOFTHELEGS5.Nowholdingbotharmsinfrontofyou,maketwoExaminationofthelegsfistsandcockthewristsbackwards,stopmefrommovingthewrists.Nowcockthewristsdownwardsrdliketoassessyourwalking.LetmeseeyouwalkwhileItrytostopyou.Nowdothesamefingers.round.Justslowly,walk20or30feetawayfromme,6.Stretchallyourfingersoutstraightandstopmeandturnaroundandwalkbacktowardsme.frombendingyourfingers.RelaxyourlegswhileImovethemaroundslowly,7.Nowcurlyourfingersuptightlyintomyfingersnow,letmeseethestrengthinthemuscles.Liftyourandmakeastronggrip.Keepthefingerstightlylegsupintheairandholditstraight,now,letmecurledup.lookattheotherside.Nowputthelegdownflatonto8.Nowsqueezemyfingersastightlyasyoucanintheexaminationtable,nowtheotherside.bothhands.Bendthekneeandkeepitbent,stopmefrom9.NowspreadyourfingerswideapartwhileIteststraighteningit,now,kickthelegstraightagainstme.thesmallmusclesinthehand,stopmefrompushingFlexyoufootuptowardsyourfaceandstopmefromthefingerstogether.....Ok,verygood.pullingitdown.Nowpushthefootawayfromyoutopushmeaway.NowI'mgoingtoexaminethesensationonyourTurnthefootsothesoleofthefootisfacingtheskin,keepyoureyesclosedthroughouttheotherfootandkeepitthere.examination.Nowturnthesoleofthefootoutwardsandkeepit1.I'mgoingtotouchtheskinofyourarmsinvariousthere.Stopmefromstrengtheningtheankle.differentplacesjustusingalighttouchwithcottonwool.Say"yes"everytimeItouchtheskin.I'mgoingtotouchyouwithasmallpieceofcotton2.NowI'mgoingtotestthesamefeeling,butusingwoolontheleg,shutyoureyesandsay“yes”whenaprickofapininsteadofcottonwool.Say'yes”youfeelthetouchofthecottonwool.Iwanttoeverytimeyoufeelthetouchofthepin.Canyoufeelcomparethetwosides.Tellmeifthetouchfeelsthethepinprick?Doesitfeelthesameonbothsides?sameontheleftlegasitdoesontheright.3.NowI'mgoingtoassesswhetheryoucanfeelNow,I'mgoingtotestthesensationusingapinprick,vibration,I'llstartwithyourhand.Tellmeifyoucantellmewhetherthere'sacleardifferencebetweenthefeelthevibrationofthetuningfork.touchofthepinandthecottonwool.4.Finally,I'mgoingtoassesswhetheryoucanfeelCanyoufeelthevibrationofthetuningforkwhen1yourfingersbeingmovedupanddown.Tmgoingtopressitontothebonesinyourankle.holdyourlittlefingerandmoveitupanddownFmgoingtowiggleyourbigtoeupanddown,shutslowly.Shutyoureyes,andwhenyoufeelthefingersyoureyesandsay"up”whenImovethetoeup,moveupsay"up"andwhenit'sdownsay“down”."down"whenImovethetoedown.NowI'mgoingtotestthereflexesinyourarms.133HEADACHERelaxyouarmsandFiltapthereflexesofthebicepsHeadacheandthetricepsmuscles,andalsothesupinatorreflex.Fmgoingtotestthereflexesinyourlegs,relaxyourTellmeaboutyourheadache.legswhileItapthereflexesinthekneesandattheIgetaheadachethatcomesandgoes.ankles.Tellmewhereaboutstheheadacheis.I'mgoingtoscratchthebottomofyourfootwithaItseemstobeontherightsideofmyhead.woodenstick.Howlongdoestheheadachelastwhenyougetit?65
66Itvaries,itcanbebetweenhalfanhourandfourorneveranythingmorethanthat.fivehours.Whatdoyoudoaboutaheadachewhenyougetit?Whenyougettheheadache,doesanythingelseWell,Fvetriedtotakepillsandtablets,butnothinghappenatthesametime?reallyseemstohelp.Yes,IgetflashinglightsthatseemtobeintherightIsthereanyparticulartimeofthedaywhenyouhaveeye.aheadache?Anythingelse?Yes,itseemstobemosttroublesometowardstheendYesIfeelsick,sometimesIactuallyvomit.oftheday,butoftenil'stherethroughoutthewholeWhatdoyoudowhenyougettheheadache?dayandbuildsupduringtheevening.Well,TmnotabletocarryonwithwhatI'mdoing,Ihavetogotoadarkroomandliedown.134HEADINJURYHaveyoufoundanymedicationthathelpstheHeadinjuryheadache?SometimesifItakeanaspirinearlyinthecourseofIinjuredmyheadtwoweeksago,Iwasinacartheheadachetheaspirinseemstohelp.AtotherwhichwashitfrombehindandIbangedmyheadontimesnothingseemstohelp.thewindscreen.Iwasknockedoutforafewseconds,Doesanybodyelseinyourfamilyhavethissortofaand1wastakentohospitalinanambulance.Theyheadache?examinedmeandsaideverythingwasallright,butYes,mymotherusedtosufferfrommigraines,butsincethenI'vehadheadacheswhicharethereallthethatwaswhenshewasyounger.time.Ihavedifficultyconcentrating.IfindIcan'tTellmeaboutthepain,doesitseemtobesharporrememberpeople'snamesandtheheadachestopmedull?Isitjustconstantacheordoesitseemtobefromsleepingatnight.throbbing?Ithinkwe'lldosometestsandtakeanx-raytocheckItthrobs.outwhat'shappened....thetestshaveshownthatyourheadachewasduetoaburstbloodvesselinsideTellme,howoldareyou?thehead.ThescansshowthatthereisaweakareaonPm29.thewallofoneofthebloodvesselsinyourheadHowlonghaveyoubeenhavingthisheadache?calledananeurysm,andthisweakareainthewallIhavehadthemforseveralmonths,theyseemstohasburst.Sotostopthishappeningagainweneedtohavebeenthereformostofthepastyear.doanoperation.Whatwe'lldoisidentifythebloodCanyoudescribetheheadache?vesselwiththeweakarea,andthenwe'HplaceaThey'relikeabandallaroundmyhead,sometimeverysmallmetalcliparoundtheaneurysmtostopittheylikeaweightpressingdownonthetopofmyfromburstingandbleedingagain.head.Doesthepaincomeandgo?135EXPLAININGNEUROLOGICALItneverseemstogoawaycompletely,sometimesitPROCEDURESisworsethanatothertime,butit'stheremostoftheexplainingneurologicalprocedurestime.Whenyougetaheadache,doesanythingelsehappen?12.9.ASometimesIfeelslightlysick.IamgoingtoarrangeforyoutohaveaspecialtestofDoyoueveractuallyvomit?theelectricalactivityofthebrain,whichiscalledanNo,Ijustfeltsick,I'veneveractuallybeensick.EEGorelectroencephalogram.We'llaskyoutolieDotheheadachesupsetyoureye?downonthecouchandthenthetechnicalstaffwillSometimesIfeelthatmyvisionisalittleblurry,butconnecttoyouuptoabout20smallelectrodeswhich66
67westicktothesurfaceoftheheadusingspecialglue.plasteroverthesitewhereIdidthelumbarpuncture.We'llthenjustaskyoutorelaxandliestillwhileaAndthenI'llaskyoutolieflatforaboutanhourafterspecialmachinerecordstheelectricalactivityofthethelumbarpuncturetoreducetheriskofgettingabrain.Sometimesduringthistestwe'llaskyoutoheadache.breatheveryfasttoseeifthatchangestheelectrical12.9.Dpatternthatwerecord.WellalsoflashabrightlightWearegoingtodoascanofthebraincord,CTscanveryquicklybecausethisalsocanchangethepatternorCATscan.Thisisaneasytest.Youjustneedtolieofelectricalactivitythatweseeonthetracingthatonthespecialstretcherwhichmovesandrunsintoweget.theheadscanner.Itisalittlebitlikeputtingyour12.9.Bheadinalargewashingmachine.YouliestillandWearegoingtodosomesmallelectricalteststolookyouwillhearthemachinemakingnoiseswhileitattheefficiencywithwhichthenerveareworking.takessomespecialcross-sectionalX-raystogiveusThefirststageofthistestistomeasurethespeedofapictureofyourbrain.conductionofimpulsesinthenerves.Todothiswe'll12.9.econnectyouuptosomeelectrodesandgiveyouaWearegoingtodoaspecialscanofthebraincalledverysmallelectricalimpulse.WecanthenmeasuremagneticresonanceimagingscanorMRIscan.Youthelengthoftimeittakesfortheimpulsetotravellieonastretcherthatslidesintoalongtunnelwhichthroughthenerves,andthemachinewillrecorditonisthescanneritself.Youneedtoliestillforabout10thescreen.Thisfeelslikeatickleandisnotor15minuteswhilethemachinebuildsupcrossunpleasant.Asweincreasethestimulus,youmaysectionalpicturesofthebrain.Thistestisquitenoisyfeelasmallelectricalshock.Itwillmakeyourthumbandyouwillhearalotofthumbingandbangingofyourfingersjump.Thesecondstageofthetestisnoiseswhilethemachineworks.Youmayfeeltomeasuretheelectricactivityinthemusclesclaustrophobic.Sowe'llgiveyoualittlerubberpumpthemselves.ThisiscalledanEMG.Weneedtoputatohold.Ifyoureallyneedtocomeout,justpressthesmallneedleundertheskinintothemuscles,andpump.thenIwillaskyoutomovesomeofyourmuscles.Thiswillthenallowmetorecordtheprogressofthe136ROUTINECHECK-UPelectricalactivityinthemusclesonthescreen.Routinecheckup12.9.CWewanttoexaminethefluidwhichcirculatesHaveyoubeenhavinganyproblems?aroundthebrainandspinalcord,calledcerebrospinalIhavebeengettingtoothache.fluid,CSF.TodothiswearegoingtodoalumbarCanyoudescribethepainforme,isitasharppainorpuncture.Iwantyoutolieonyourleft-handsideonisitadullpain?thecouch.ThenIamgoingtocleantheskinontheIt'squiteadullpainandmyfaceisswollen.backwithsomeantisepticsolution.You'llthenfeelIsthetoothsensitivetohotandcold?megivingyousomeanestheticintotheskintomakeYes,ithurtswhenIdrinkanythinghot.thesurfaceoftheskingonumb.OncetheskinisIsthetoothtenderwhenyoubiteonit?numb,youwillfeelalittlebitofpressureandYes,it's.pushingandpullingWhileIputaveryfineneedleDoesithurtjustduringthedayoratnightaswell?throughtheskinbetweenthebonesofthebacktoletIthurtsallthetime.metakeoffsomeofthespinalfluid.IwillmeasureYourtoothisinfected,andtheremightbeanabscessthepressureinthefluidandthencollectseveralunderit.Tilgiveyouantibioticstoreducethesamplesofthefluidtosendawayforanalysisintheinfection.Iftheswellingdoesn'tgodown,I'mafraidlab.OncetheneedleistakenoutI'llputasmallfl!havetolanceitorperhapsdraintherootcanal.I67
68wantyoutoreturninaweek,andI'Hputagoldpostsalivarysuction/sucker/ejectorinyourmouthtointhetoothbeforeIcrownitforyou.Assumingtheremovethesaliva.WhenFvedonethat,Tilbeusingrootcanaltreatmentissuccessful.Weusuallyleaveaslowerdrill.Thiswillvibratequitealot,butIneedthetoothtosettleforthree/sixmonthsbeforetodothattotakeoutthedecaywhichwillbeundercrowning.theoldfilling.IfthedecayhasgonequickdeepintoyourtooththenI'llusesomethingwecallanCanyoudescribethepain,doesithurtjustduringtheexcavator.It*sasmallspoon-liketoolwhichwilldayoratnightaswell?scrapeoutallthedecay.Isitsensitivetohotandcold?Hasyourfacebeenswollen?Ok,Tilstartthatrightnow.ok,nowthenwe'veIsthetoothtenderwhenyoubiteonit?movedtheoldfilling,I'vetakenoutthedecayunderthefilling,nowFmgoingtoputtinginalining,in137ROUTINEFILLINGthiscaseit'scalciumhydroxide.ThefactisthisisanRoutinefillinginsulatinglayerwhichinsulatethetoothfromthefillingsothattheheatpassingthroughthefillingGoodmorning.Comein,sityourselfdown.Now,doesn'lreachthenever.Fveputthatin,nowFmI'mgoingtogiveyouasmallroutinefilling.First,Igoingtoputastripofsteel,thematrixretainer,needtogiveyouaninjection.Beforetheinjectionaroundthetooth,andthenI'mgoingtoputintheI'mgoingtoputsomecreamonyourgumtomakeamalgamtofillinthetooth,amalgamisthenormaltheinjectionlesspainful.Icoulduseaspraybutthissortoffillingwhichweuse.Ok.Offwego,ok,nowtimerilusecream.Tmgoingtoputthisscreamonathefillingisallinplace.Tdlikeyoutovery,verysmallcottonwoolroll/swab/,andputitnexttoyourgentlybiteonthefilling,thenIcanseeifthere'sanytooth.Now,justleaveitforafewminutesandthenpartthat'salittlebithigh.Ok,biteverygentlyplease.whenitstartstotakeeffect,becauseit'sanupperNow,moveyourjawfromsidetoside.Right,open,tooth,I'mgoingtoputtheinjectionnexttoyourthankyou.Ok,thefillingisalittlebithigh,soI'Htooth.IfitwerealowertooththenIwouldputtheshaveitoffalittlebit.Ok,bitetogetheragain,veryinjectionintheblackofyourmouthandthatwouldgently....,ok,sidetoside,open,ok,yes,Ithinkthatmakethewholeofyourjawnumb.Now,I'llputtheisgood,fine,howdoesitfeel?Now,I'dlikeyoutoinjectionnexttoyourtoothhere,andthatwilltakecomebackinaweektime.abouttwominutesbeforeittakeseffectonthetooth.Inthemeantime,whatI'HdoisI'HscaleandpolishThereisanotherfillingtodoandI'dalsoliketoyourtooth,andthatmeansI'mgoingtotakeoffthepolishtheamalgamsurfacesothatitdoesnotattractplaquethatgrowsaroundthesalivaryglands.Andfood,Ssothefooddoesn'tsticktoit.Thankyoupolishthemup.verymuch.Seethereceptionistonthewayout.I'msorry,thereisonemorething,trynottoeatontheOknow,Theinjectionhasworked.TvescaledandsidewherethefillingisforthenexttwoorthreepolishedyourteethandFmgoingtostartdoingthehours.Bytomorrowmorning,it'lldefinitelybesetdrillingnow,I,mgoingtotakeouttheoldfillingsolid,soyoucaneat.Justfortwoorthreehours,eatbecauseit'sleakingononeside.Forthis,weyouontheothersidepreferablyavoideatingtogether.Ok,excusemeifwewearmyprotectiveglassesbecausethanksalot,seeyounextweek,bye-bye!thisdrillworksveryveryquicklyanddebriscanflyoutofyourmouth,andhitmeintheeye.Tmalso138BRIDGEWORKgoingtoputonmyprotectivefacemask.Now,I'llbridgeworktakeouttheoldfilling.Firstofall,Ihavetoputthe68
69Ithinkyouneedsomebridgework.Thisisabecausetheinfectionisnotsevere.Somepeoplereplacementofatoothbyafixedmetalframework.IthaveaverysevereinfectionwhichwecallVincent'susuallyinvolvescrowningyourteethoneithersideanginaandforthatIhavetogiveadrugwhichisofthespacewiththefalsetoothbeingweldedontocalledFlagyl,whichistakenforafewdaysanditthemetalsubstructure.Thewholeofthebridgeisclearsitupveryquickly.Yourconditionisnotasusuallycoveredbyafacingofporcelain.Therearesevereasthat,andwithgoodbrushing,onceI'vetwokindsofbridgeworkyoucanhave.First,removedthecalculus,wecanrestorethegumstofixed-fixedbridges.Thesehavetobetreatedwithhealth.Ifyouhadaslightlymoresevereinfection,greatcare.Theymustneverbeabused.TheymustI'dhavetoprescribeCorsodylwhichisaveryneverbeusedforbitinganythingtoohardortooeffectivemouthwash.Theonlyproblemisthatitsticky.Andyoumustmakesurethatyouhavetendstodiscolorthatrestoftheteeth.cleanedthemextremelywell.Thenthereisadhesivebridge.Thesearebasicallyheldinplacebyboned140ORTHODONTICSwings.ThewingsofthebridgewhichfitroundtheOrthodonticsadjacentteethareetchedandweuseabondingtechniquetobondthebridge.TheyarenotasrobustOkdocomein.so,you'renotveryhappywiththeasthefixed-fixedbridge,butthegreatadvantageofappearanceofyourteeth.Youseemtothinkthey'rethemisthattheydon'trequiretoomuchtoothstickingoutabit.Okthisiswhatwedowhenwedestructionandintherightconditionsntheycanbehaveaproblemlikethis.Firstofall,we'lltakesomeextremelyeffective.....I'mgoingtotakeanimpressionsofyourteeth,thatmeansmakesomeimpression.Tmgoingtofillthistrayupwithapinkplastermodelsofthem.We'llalsotakesomex-rayspaste,whichrilpop/put/intothetrayandthenrilandacoupleofphotographsandthenwecanstudyputthetrayoveryourteethforaminuteortwo.thesecarefullyandeventuallydecideifyouneedanyBreathethroughyournosenormally;relaxyourtreatment.Butwehavetogothroughtheseinitialcheeks,lipsandtongue.planningstages.Ifwedecide,orIshouldsay,ifyoudecidethatyou'dliketogoaheadwithsome139BLEEDINGGUMSorthodontictreatment,straighteningyourteeth,thenBleedinggumstherearetwotypesofbracesorappliancesthatwecanuse.Oneisafixedappliance,that'sanapplianceOk,nowyoutellmethatyouhavebleedinggums.whichstaysinallthetime.NowadaysweactuallyWhenyoubrushyourteeth,yourgumsbleed.Now,stickthis,almostglueit,toyourteeth,andthatlockssurprisingly,thisiscausedbynotenoughbrushingontoyourteeth.Thenweputwiresbetweentheteethratherthantoomuch.What'shappeningisthatwhichcanmoveorrotatetheteethinthewaythatwethere'sanaturalbuild-upplaqueandcalculusonwant.yourteeth.BothofwhicharequitenaturalandTheothertypeofappliancethatweuseiscalledthenormalbuttheyhavetoberemoved.That'swhyweremovableappliance,andthisisonethatyoucanbrushourteeth.takeinandoutforcleaning.OneveryimportantNow,what'shappeningisthatyouarenoteffectivelypointyouhavetorememberwithanyapplianceismovingplaqueandcalculus.Thecalculus,Iwillyou'vegottokeepyourteethclean.IfIt'safixedremove.Tmgoingtoscaleyourteethtogetofftheappliancethisisevenmoreimportant,becauseyouharddeposittheflossingandtoothbrushingcan'tcan'ttakeitouttocleanit,soyouhavetovery,veryremove.Youhavetogetridoftheplaqueyourselfbycarefulaboutbrushing.Alsothefixedappliancecanbrushing.AndnowI'mgoingtogiveyouarubagainstyourcheeksoragainstyourgums.Inthatdemonstrationofhowtodothis...ok,youareluckycaseifthatweretohappen,Tilgiveyousomesoft69
70redwaxwhichyoucanpackaroundtheappliance,Italwaystakestimeandpracticestogetusedtonewwhichsortofpadsitandstopsitfromrubbing.Okdentures,andintheearlydaysyoumaygetasorewell,Ithinkthat'sallyouneedtoknowfornow.mouth,ifyoudohaveanyulcerationyou'readvisedlet'sgoaheadandtaketheimpression....toreturntothepractice/dentist'soffice/.Nowthatyouhavehadthebracefitted,you'regoingCleanyourdenturesusingsoap,warmwaterandatohavetobeextracarefulaboutcleaningyourteeth.nailbrush.LeavethedenturesoutatnightbecauseifYouroralhygienewillhavetobeverygood.Maybeyoudon't,you'relikelytogetdenturesores,whichyourteethwillfeelrathertenderforafewdays.ThisarecausedbyCandidaalbicans.meansthatthebraceisdoingitsjob,andtheteethareI'mnotsurprisedyou'recomplainingaboutsorenessbeginningtomove.Thesorenesswillgoawayafteraatthecornersofyoumouth.Icanseethatthey'recoupleofdays.I'mgoingtogiveyoursomeofthislookingredandcracked.Nowthisisaconditionredwax.Ifyourgumsorcheeksgetsorejustputwhichwecallangularcheilitis,whichisatechnicalsomewaxontheappliancewhereitisrubbingandittermreferringtoafungalinfectionwhichgrowsatwillactlikeaplastertoprotectyourmouth.thecomersofthemouth.Itiscausedbyill-fittingdentures,sowehavetoconsiderre-makingyour141Followingextractiondentures.WouldyouopenyourmouthalittlebittoFollowingextractionstopthoselittlecreasesandfoldsappearingatthecomersofthemouth.Inthemeantime,TilgiveyouOk,well,that'sthetoothout.(thattoothisout).Nowtwothings,TmgoingtogiveyousomelozengeswhatrdlikeyoutodoistobiteonthiscottonwoolwhichIwantyoutosuck.They'llreleaseintoyourroll/swab/forabouttentotwentyminutesuntilthemouthsomeantifungalagentwhichwill,hopefully,bleedingstops.Iwantyoutobiteashardasyoucankillthefungalinfectionatthecornersofyourmouth.andjustwaitinthewaitingroom,andFilseeyouinAlso,I'mgoingtogivesomepaintwhichIwantyoutwentyminutes.Oknowletmecheckandseeifthetopaintonyoudentures.Thiswillslowlyreleasethebleeding'sstopped.Yes.Thatlooksniceanddry.Ifantifungalagentintoyourmouthwhichwillthebleedingstartsagain,anditmight,it'snoteventuallyclearuptheinfection.Iwantyouunusual,Tdlikeyoutotakeacleanhandkerchiefandespeciallytotakeyourdenturesoutatnight.Thisbitehardonituntilthebleedingstops.Don'twony,willgiveachanceforthelipsandthecornersofyourthat'squitenature.Trytokeepfoodawayfromthemouthtohealmorequickly.Whenyoutakethemoutextractionarea,eatontheothersideandrinseyouratnight,makesuretoputtheminwater.mouthoutaftereating.Nowthiswasquiteabigextraction,andwe'vehadtoputastitchinasyou143MOSTCOMMONLYSEENDISEASESknow.I'mgoingtogiveyousomemouthwashMostcommonlyseendiseaseswhichwillhelptorelievepain,anditwillhelptoreducetheinflammationandhelpthehealing.It'saAlsoknownastoothdecay,itisthecommoncausebottomtooth,bottomteethtakemuchlongertohealoflosingteeth,uptoabouttheageof55.upthanatoptoothsobepatient.Ifthere'reanyproblemsatall,anypain,anywhitenessaroundtheThisisadiseaseaffectingthegumswhichiscausedextractionsite,pleasecomebackandseeus,andwebyabuild-upofplaqueandbacteriaaroundtheneckcandosomethingaboutit.ofthetoothwhich,ifnotremovedbythepatient,formstartarorcalculus.142NEWDENTURES,ANGULARCHEILITISNewdentures,angularcheilitisThisisconcentrationofthemineralsaltswhichirritatesthegumcausinganinflammatoryresponse70
71whichresultsinitiallyingingivitis.Thisisareddeningandswellingofthegumswithbleeding.Ifitisnottreatedthenitwillcausefurtherirritationwhichresultsinthebonesurroundingthetoothbeinglost,whicheventuallywillcausemobilityandthetoothwillbeshed.Theseusuallyrequireantibiotictherapyfollowedbyscalingandroot-planingifthetoothistobesaved.Thecauseisnotknown/autoimmunedisease/.Thetreatmentisusuallybyprescriptionoftheeithermouthwash,benzydaminehydrochloride/Difflam/,orTriancinolonepaste,whichisanextremelystrongsteroid,extremelygoodforthetreatmentofthisulceration.Gingivitisdentalcariesabscess/ulcerationperiodontaldiseasecalculusacutebacterialinfections71
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