By P. Muntasir. University of Colorado, Denver.

I also was beginning to sense the need for physicians to exam- ine their own beliefs and separate those that are important for the patient from those that are important to themselves discount 300 mg sinemet with mastercard. My extreme need at the time to use accurate medical terminology overrode what might have been best for the care of this frightened girl and her family. Up until this point, I had assumed that assigning a nonexistent disease name to a patient was just sloppy medicine, a poor method for dealing with symptomatic patients. I now see the error of overdiagnosing a nonexistent disease as powerful evidence for why we need to abandon the biomolecular model for clinical medicine. It was not until I reflected on Sweet 60 Symptoms of Unknown Origin Ting and my own errors in her management that I came to this broader view of the origins of the error of nondisease. It is an error demanded by a paradigm that restricts diseases to either the body or the mind. Tis paradigm relegates human beings to an isolated island of brain, other organs, tissues, cells, and molecules disconnected from the narrative of life. Since returning to Vanderbilt and Saint Tomas, I had begun to see a large number of referred patients. Word got around that I was interested in seeing patients who had symptoms of disease but no objective evidence of disease. Some referring physicians called them by pejorative terms—crock or turkey or shad. I arrived at a standardized approach for patients with symp- toms of unknown origin (SUO) referred to me for management or for consultations. I did not use this standardized approach when the medical diagnosis and thus the therapy were obvious early in the visit or consultation. I would not make a diagnosis unless I had convincing evi- dence for the presence of the disease. I would do a comprehensive medical workup on each pa- tient, focusing on the symptoms when appropriate. I would continue to tell the patient about those diseases that I knew with near certainty were not present. I would not attempt to make a psychiatric diagnosis except for depression, which I saw as a treatable and diagnosable disease.

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For example cheap 300mg sinemet with visa, more entry to human host cells by binding to receptors on than 150 viruses infect the human respiratory tract, includ- cell membranes. All human cells do not have receptors ing approximately 100 types of rhinovirus that cause the for all viruses; cells that lack receptors for a particular common cold. Viruses can be spread by secretions from in- virus are resistant to infection by that virus. Thus, the fected people, ingestion of contaminated food or water, locations and numbers of the receptors determine which breaks in skin or mucous membrane, blood transfusions, host cells can be infected by a virus. For example, the sexual contact, pregnancy, breast-feeding, and organ trans- mucous membranes lining the tracheobronchial tree plantation. Viral infections vary from mild, localized dis- have receptors for the influenza A virus, and certain ease with few symptoms to severe systemic illness and death. Re- Cytomegalovirus Disease and Retinitis covery from the primary infection leaves latent infection in nerve Cytomegalovirus (CMV) infection is extremely common, and most cells. Reactivation of the latent infection (usually later in life) people become infected by adulthood. Infection is usually causes herpes zoster (more commonly known as shingles), a lo- asymptomatic in healthy, immunocompetent adults. Like other her- calized cluster of painful, blister-like skin eruptions. The skin le- pesviruses, CMV can cause a primary infection, then remain latent sions have the same appearance as those of chickenpox and in body tissues, probably for life. Over several days, the vesicles become pustules, in secretions of an asymptomatic host and spread to others by con- then rupture and heal. Because the virus remains in sensory nerve tact with infected saliva, blood, urine, semen, breast milk, and cer- cells, pain can persist for months after the skin lesions heal. It also means the virus may lead to an opportunistic cases of herpes zoster infection occur among the elderly and the infection when the host becomes immunosuppressed. Two types of HIV virus have been identified, HIV-1 and congenital CMV infection.

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The life stories of peo- ers who serve as caregivers play a critical col- ple also offer new textures in a familiar world laborative role in setting and revamping goals that help rehabilitation clinicians enjoy their and in carrying out supportive and therapeutic work and empathize with their clients 300mg sinemet for sale. Patients must be taught that their team must also monitor how patients see them- active participation drives the possibility of selves through the course of rehabilitation and gains. Rehabilitationists do not possess holy wa- how spouses and other caregivers view them. Reading and discussing stories The Rehabilitation Team 215 from the literature of medicine, from the per- best serve short-term functional goals and on- spectives of patients, families, doctors, and oth- going medical and rehabilitative care pose ers, can help the team examine and find a con- complex design problems. Economic pressures text for the nature of their interactions and goals will likely push service providers to develop less (see http://endeavor. Cheerleading and positive reinforcement by These changes may include greater use of ther- the team is supportive, but therapists have to apy technicians and supervised aides who func- be careful not to talk down to a patient or of- tion across disciplines, as well as group ther- fer therapeutic activities that come across as apy, treatments done by recipe-like protocols, too simple-minded. Other tients who are used to taking charge may re- settings may come into greater use than inpa- ject therapy if they believe that they are being tient hospital care, such as skilled nursing or infantilized. The team often expends great ef- transitional living facilities, day care, and home fort into juggling its own notions about what is care. Therapy may be limited to a short list of and shying away from paternalism. Patients and families must come to un- tional outcome measures such as the FIM. The cilities often ask their patients about satisfac- ethical challenge for the providers of therapies tion with their experiences. Table 5–1 poses is to come to an agreement with the client some commonly asked questions of patients at about realistic medical, functional, and quality- the time of discharge from inpatient care that of-life goals. Agreement is especially important also get at the responsibilities of each member since the team, not the patient and family of the team. This decision is individual leadership must be taken to manage often made under some pressure by the health the medical, neurophysiologic, functional, cog- care insurer to halt services that are not med- nitive, psychologic, social, educational, and vo- ically necessary. Studies of inpatient stroke rehabilitation sup- port the approach primarily as an efficient means to organize services for patients with PHYSICIANS functional disabilities.