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The court finding was that Section 260 (granted leave only if the doctor could be shown to have acted in bad faith or without reasonable care) was unconstitutional having regard to Articles 6 and 34 of the Irish Constitution order generic arava pills symptoms 7dp3dt. In Britain the number of unfilled psychiatric posts was a worry 20mg arava otc treatment nausea,(Storer purchase arava overnight delivery medications and mothers milk, 2002; Brockington & Mumford, 2002) as are the posts filled in a temporary capacity in Ireland. Here, as in our neighbouring country, foreign ‘drives’ were undertaken to procure junior doctors and nurses, both of which are in short supply. In America there has long been a flight from public psychiatry into the better-paid private sector. Keogh ea (1999) suggested that there would be no bed problem if there were somewhere to transfer non-acute patients. Services need to be designed with the local environment in mind,(Bebbington ea, 2002) e. It is far from clear that intense community-focused care reduces cost or improves clinical status. Craig ea (2004) found a non-significant effect on relapse of assertive outreach over standard care, with only reductions in total number of re-admissions and dropout rates being attributable to the former approach. No firm conclusions could be drawn from this research because of the ‘modest sample size’. Johnson ea (2005) used a 24-hour crisis resolution team to augment existing acute services and found that hospital admission was rendered less likely over the ensuing eight weeks; however, compulsory admission rates were not significantly altered. Assertive outreach teams in North East England appear to be reaching the most severe cases (Schneider ea, 2006) but community mental health teams in North London are as effective with such cases as are assertive outreach teams, although the latter may be better at engaging clients and may be better appreciated. Whilst Dibben ea (2008) found that a crisis resolution and home treatment team reduced hospital admissions for elderly people but there was no important change in length of stay once in hospital and carers may have been happier with the service than were patients. A Welsh study (Tyrer ea, 2010) found that crisis resolution and home treatment teams reduced voluntary admissions at first but that involuntary admissions increased later on. McCrone ea (2009) reported that a South London crisis resolution team saved money when compared to existing services. Hospitals are still collecting ‘new long stay’ patients such as the young, single male schizophrenic with a history of violence or the middle-aged female with affective disorder or 3281 dementia. New long stay patients, defined as those cases needing longterm inpatient care and refractory to extensive rehabilitatory efforts, were accumulating at a rate of 0. Cognitively damaged patients are particularly difficult to rehabilitate and require high levels of support. The cases that were decanted first from institutions tended to do relatively well if their discharge was planned, but the remnant population was much more damaged, i. The population is getting older and this brings with it increasing levels of chronic morbidity and demands for total care. The mushrooming of nursing homes is paralleled by the increasing use of psychotropic drugs to contain behaviour because of the lack of other feasible alternatives. Psychiatrists are increasingly been ask to do something about elderly patients whose ‘depression’ or ‘paranoia’ or disinhibited behaviour is only one aspect of a multiplicity of organic disorders. It should be recalled that resources were scare because monies had been diverted into President Kennedy’s community mental health centres which catered for the less seriously ill. Rather than simply taking from better-funded areas, the lesser-funded areas require greater funding. Survey of Irish psychiatric services (O’Keane ea, 2003) (1 consultant/each of 32 catchment areas completed questionnaire) Over-stretched and developed on ad hoc basis Best developed in most affluent areas (negatively correlated with an index of relative deprivation, i. The College of Psychiatry of Ireland (Barry & Murphy, 3282 Poor outcomes are associated with patients’ perceptions of being ignored or disrespected. Whereas 74% of mentally ill Europeans receive no treatment, the comparable figure for diabetes in only 8%. A Gloomy View: Rhetoric or Reality in Relation to the Advancement of A Vision for Change. The Lie of The Land: Psychiatric Service Land Disposal & Failures and Delays in Capital Development of Community Based Mental Health Services. Proceedings of the Joint Conference of the Equality Authority and the Irish Medical Organisation. Evaluation of a Pilot Project for Home-Delivered Care for Patients with Acute Mental Illness in North Kildare. Position Statement on Psychiatric Services for Children and Adolescents in Ireland. Reconnecting with Life: Personal Experiences of Recovering from Mental Health Problems in Ireland. Code of Practice on Admission, Transfer and Discharge to and from an Approved Centre. Report of a Study Group on the Development of the Psychiatric Services (Trant S ea). Happy Living Here…A Survey and Evaluation of Community Residential Mental Health Services in Ireland. Report of the Inspector of Mental Hospitals for the Year Ending 31st December, 2003. Every treatment approach has its devotees and it is important to keep this in mind when evaluating evidence, e. The mind and brain are interdependent and neuroimaging shows brain changes after either psychotherapy or physical treatments. Behaviour therapy for anxiety disorders leads to attenuation of abnormalities on brain images in expected areas and activation of regions connected to positive interpretation of stimuli that otherwise lead to anxiety. Some patients simply want to gain greater control over their feelings, even if their symptoms survive, whilst others seek symptom removal. Supervision by an experienced and interested therapist offers the best teaching milieu. Greben (1981) defined psychotherapy as any form of treatment strategy wherein a trained individual associates with a person who is looking for help and who, by listening and talking to him, the therapist helps him. Fisk (1993) bemoaned the tendency of psychotherapists to identify with specific schools rather than with the whole field of psychotherapy. Undoubtedly, no matter what the technique employed, the personal skill of the therapist is highly relevant to outcome. The biggest problems with psychotherapy are poor availability (Guthrie & Sensky, 2007, p. He/she must experience pain born out of the individual interactions with patients, reminders of our own unresolved problems. His/her elders must not take flight into administration or academia, or give the example of defensive hostility towards patients. Personal and clinical maturity comes with time and interaction with real patients, who can be very demanding, as can their relatives.

With improbable speed buy discount arava 10 mg online medications for rheumatoid arthritis, the Campaign and its supporters in the Department of Health got an investigation by the Medicines Control Agency into both Yves Delatte and Monica Bryant 10mg arava sale symptoms retinal detachment. The charges related to the possession and sale of unlicensed medicines buy arava 10 mg with visa treatment bronchitis, and the supply of those medicines to patients without a licence. Dreer, who had been advised by his solicitor to plead guilty, appeared in court on behalf of the Company which he and Delatte had set up. In fact, there has never been any dispute about the fact that lactic acid bacteria are food supplements and not medicines. Yves Delatte was also charged personally and his plea was entered by his solicitor in his absence; much later in January 1992, he was fined £350 plus costs. Bryant was prosecuted by the Department of Health for articles she had disseminated on selenium, chromium and germanium. She was accused under the Medicines (Labelling and Advertising to the Public) Regulations of making medical claims for these trace elements. The acquittal hearing was held in July 1991, at Brighton Magistrates Court, where Bryant was awarded nearly £11,000 in costs from central funds. It took over three years for Monica Bryant to become confident enough to trust a limited number of people and to venture out into the world again. Yves Delatte is still fighting to gain access to his children, and prove in a Finnish court that he is not the monster which Campbell claimed. Sandra Goodman was forced into a temporary retirement from scientific research, although her energy is undiminished. Looking back on the whole affair which has damaged his life and career, Yves Delatte remembered something said by Dr Connolly when they were chatting about the Concorde trials. A Contemporary Salem: Elizabeth Marsh nl The issue was very simple, I had treated a cancer patient When Elizabeth Marsh decided to become a therapist and a healer, her decision had nothing to do with any well-ordered course of medical training, or any previous history in the field of health. Until 1981, when she was suddenly deserted by her business partner who left her with an £80,000 debt, Elizabeth Marsh had made reproduction antique dolls. In the middle of this turmoil and having to move out of her house, she suffered the loss of her brother from cancer. Following this period of crisis she set about, in any possible way, outside of orthodox medicine, learning about cancer. Later in 1981, she travelled to Romania, where she worked and studied at the National Institute of Gerontology, in Bucharest, with Professor Ana Asian. Following the year in Romania, from 1986 to 1987, Marsh joined the Bedfont Theological Seminary, a theological college which specialises in healing. On the conclusion of her training in 1988, she was ordained as a Minister, and also received a PhD, which entitled her to use the title doctor. Over the next ten years, the diverse and unusual training which Elizabeth Marsh went through, together with the tides which she used, were to attract the attention of health fraud campaigners. It would indeed have been surprising, if in her journey through the far reaches of alternative therapy, Elizabeth Marsh had not been associated with one or more of the organisations on the lists of the American Council Against Health Fraud. Other things, as well, have brought American Biologies into direct confrontation with the orthodox pharmaceutical medicine lobby. Bradford, the Institute carries out research and publishes on subjects as diverse as cancer and nutritional therapies and chelation therapy. When Elizabeth Marsh came back from training in America, she brought with her an American Biologies microscope produced for the diagnostic analysis of live blood cells. She became one of the first people in Britain to begin diagnostic work using this equipment. In September 1988, Elizabeth Marsh set up a therapy centre in Ealing where she began practising homoeopathy, electro-acupuncture and signalysis treatment. The practice took off well, and within months she was seeing between forty and sixty clients a week. From the beginning of her practice, Elizabeth Marsh was always scrupulous about telling patients that she was not a qualified medical doctor and asked people who came to her to sign a form acknowledging that she had told them this. She also told patients that they should inform their general practitioner about the treatment they received from her. Problems began with her practice in May 1989, the very month that the Campaign Against Health Fraud held its inaugural press conference. In April 1989, a patient had visited Marsh with very general complaints; he claimed that he felt under the weather and was unable to sleep. A week after the consultation, Marsh was phoned by the patient who revealed that he was a reporter. He asked her a number of questions for a forthcoming article, all of which she answered. She gave him the names of all the people she had worked with and the organisations from which she had received her qualifications. As well as Elizabeth Marsh, east London readers of the People could have justifiably taken offence. It is the contention of those who work with this system that the crystal structure is not only personal to the patient but also can indicate problems in different areas of the body. Results of Signalysis tests come back to the practitioner from the Signalysis laboratory in Gloucestershire, in the form of charts. In the event, Elizabeth Marsh did not consider that the bogus patient Mark Howard needed a Signalysis test. Determined to continue her work, Marsh began seeing people at her home where she used her study as a consulting room. Julia Watson was a writer of romantic novels, under the pen name of Julia Fitzgerald. In May 1989, she had been diagnosed as having ovarian cancer; she was operated on and her ovaries and fallopian tubes removed. Despite an apparent recovery from the cancer, in September 1989 her abdomen began to swell and she became unwell again. Julia Watson had for years been opposed to orthodox medicine, she was a staunch vegetarian who even treated the family pets homoeopathically. The physical signs that she was seriously ill were obviously apparent: her swollen abdomen, distended with fluid, made her appear pregnant. Elizabeth Marsh carried out basic diagnostic tests during a three-hour consultation. However, realising that Julia probably was suffering a return of her cancer, she advised her in definite terms that she would have to go back to her hospital consultant for treatment. Three weeks later, Julia Watson phoned Elizabeth Marsh again to tell her that she had been to her hospital and had the fluid drained off, and that she had also been tested for a re-emergence of her cancer. A week before Christmas 1989, Julia Watson phoned again, this time, however, she was distraught and crying.

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However order 10mg arava fast delivery medications zanx, the Collabor- defects (nasal hypoplasia and stippled epiphy- Simvastatin entirely the fetal effects of the contained pro- ative Perinatal Project6 found an increased risk ses) discount arava generic treatment jalapeno skin burn, limb hypoplasia (particularly distal dig- gestogens and estrogens buy genuine arava treatment borderline personality disorder. Except for the modi- of defects when diuretics were used during the its), low birth weight (<10th centile), hear- Based on the animal data and limited human fed development of sexual organs, no frm evi- frst trimester in women with cardiovascular ing loss and ophthalmic anomalies. Moreover, insulin, unlike metformin, demiological data indicate that the teratogenic Methimazole and carbimazole risk of frst trimester lithium exposure is lower used initially to describe fetal malformations does not cross the placenta and, thus, elimi- produced by oral contraceptives or the related nates the additional concern that the drug than previously suggested. The clinical man- A specifc pattern of rare congenital malforma- agement of women with bipolar disorder who hormonal pregnancy test preparations (no lon- therapy itself is adversely affecting the fetus. The Population Coun- Carefully prescribed insulin therapy provides 33 during the frst 7 weeks of gestation is report- fed using this revised risk estimate. High maternal glucose levels, as may esophageal atresia with tracheoesophageal its withdrawal would jeopardize the woman or pregnancies exposed to oral contraceptives. During pregnancy, the small- Some later reviewers34 have concluded that the litus, are closely associated with a number of absent nipples; and psychomotor delay. These est dose possible for acceptable therapeutic risk to the fetus for non-genital malformations maternal and fetal adverse effects, including defects may indicate a phenotype for methim- effects should be used. Doses of tricyclic antidepres- Although many of the progestagens used as observed (one expected), a case of hypospa- unknown, but it is thought to be due to altered sants may need to be higher in pregnancy contraceptive agents, such as norethisterone dias (none expected). Theophylline withdrawal in a nasal bridge, microcephaly, micrognathia and Live attenuated vaccines are generally avoided centa occurs as early as 6 weeks’ gestation, newborn exposed throughout gestation has agenesis or stenosis of external ear canals), in pregnancy. Vaccines that give passive immuni- fetal circulation and tissues during organogen- 28 hours after delivery and became progres- vessels, tetralogy of Fallot and ventricular or zation are safe in the preconception period and esis. However, the risk appears to be malities have not been associated with topical the limitations in the available data regard- low, if indeed diazepam and the other agents Radioactive iodine therapy is contraindicated retinoids, but it is advisable to avoid their use ing safety; however, the possibility of seri- do cause birth defects. Continuous use during in pregnancy since the uptake by fetal thyroid in pregnancy and ensure women use adequate ous detrimental effects to the fetus, many of gestation results in neonatal withdrawal and results in thyroid ablation and hypothyroid- contraception. Consequently, 4 months after treatment with radioactive if the maternal condition requires the use of 131 41 iodine therapy and investigations using I in Table 4 Usage of vaccines in pregnancy and preconception. Isotretinoin reduces sebum If a woman is found to be pregnant after initiating the vaccination se- secretion and in its oral form is used for the ries, the remainder of the three-dose regimen should be delayed until treatment of nodulo-cystic and conglobate after completion of the pregnancy. Vaccination poses an unknown but theoretical risk to the de- a risk to the fetus from administration of these live virus vaccines can- veloping fetus, and the vaccine should not be routinely administered not be excluded for theoretical reasons, women should be counseled to during pregnancy. However, if a pregnant woman is at an endemic area is unavoidable and if an increased risk for exposure increased risk for infection and requires immediate protection against exists. Rubella Rubella-susceptible women who are not vaccinated because they state they are or may be pregnant should be counseled about the potential If international travel requirements are the only reason to vaccinate risk for congenital rubella syndrome and the importance of being vac- a pregnant woman, rather than an increased risk of infection, efforts cinated as soon as they are no longer pregnant should be made to obtain a waiver letter from the traveler’s physician. Data on safety, Pregnant women who must travel to areas where the risk of yellow pertussis (Tdap) immunogenicity and the outcomes of pregnancy are not available for fever is high should be vaccinated and, despite the apparent safety of pregnant women who receive Tdap. When Tdap is administered during this vaccine, infants born to these women should be monitored closely pregnancy, transplacental maternal antibodies might protect the infant for evidence of congenital infection and other possible adverse effects against pertussis in early life. They also could interfere with the infant’s resulting from yellow fever vaccination immune response to infant doses of TdaP, and leave the infant less well Zoster (singles) Contraindications: Zostavax should not be administered to individu- protected against pertussis als who are or may be pregnant. It is not known whether Zostavax can Varicella The effects of the varicella virus vaccine on the fetus are unknown; cause fetal harm when administered to a pregnant woman or can affect therefore, pregnant women should not be vaccinated. For susceptible persons, having a preg- be administered to pregnant females; furthermore, pregnancy should be nant household member is not a contraindication to vaccination. If vac- avoided for 3 months following vaccination cination of an unknowingly pregnant woman occurs or if she becomes pregnant within 4 weeks after varicella vaccination, she should be coun- life, emphasizes the need for change of prac- an overview of epidemiological (drug seled about the theoretical basis of concern for the fetus; however, vari- tice. Eur J Clin Pharmacol cella vaccination during pregnancy should not be regarded as a reason unforeseen dangers, prescribing in the precon- 1990;38:325–8 to terminate pregnancy ceptional period should in the future be on the 2. Safety of chloro- development of 6-year-old children whose Metab 1959;19:1004–11 quine in chemosuppression of malaria mothers were treated antenatally with beta- during pregnancy. Psychologi- of the American Lung Association: Treat- cal development of children who were treat- ment of tuberculosis and tuberculosis infec- ed antenatally with corticosteroids to pre- tion in adults and children. The traditional treatment of cervical carcinoma are less than 35 years of age and, cancer is either radical hysterectomy or radio- for many of these women, fertility is a major therapy to the pelvis, both of which inevitably issue1. The obvious impact on nifcantly reduced the incidence and death fertility of traditional surgery has led to the rates due to cervical cancer in developed introduction of techniques to preserve uter- countries with a concomitant increased rate ine function such as the radical trachelectomy. Whilst the benefts of cervical cal tissues to exclude more aggressive exten- screening are regularly cited, it has not been sion of disease in order to accurately stage the implemented worldwide, and defciencies are tumor6,7. However, Radical trachelectomy can be performed either patients with infertility secondary to male vaginally or abdominally depending on the Radical trachelectomy offers hope of future factor, uterine factor or unexplained factors surgeon’s preference and level of expertise. Existing data on a vaginal trachelectomy, the cervix is removed trachelectomy procedures express distress and signifcant concerns radical trachelectomy suggest factors such as along with parametrial tissue and a cuff of vagi- regarding conception and pregnancy lasting cervical stenosis or adhesion formation may Radical vaginal trachelectomy for up to 6 months19. Apart from the physical cause subfertility15,23 24,, as is also the case na by the vaginal route with a simultaneous laparoscopic pelvic lymphadenectomy8,9. The recovery from an operative intervention, the when lack of cervical mucus, subclinical sal- uterine body is left intact and a non-absorb- A total of 790 patients have reportedly under- uncertainty of conception and the acknowl- pingitis and subclinical chronic endometritis gone radical vaginal trachelectomy in pub- edgment of the potential for a high-risk preg- are present24–26. With potential concerns (stenosis, sexual function, tially a similar procedure, albeit involving an laborations with fertility specialists should be a tumor size of less than 20mm and a depth reproduction) and providing referrals for developed for optimal counseling and manage- abdominal approach. Hence, nal dilator therapy and vaginal moisturizers which included 16 studies involving 355 radi- (24%), dysplastic Pap smears (24%), irregular radical vaginal trachelectomy is reserved for is extremely benefcial in addressing vaginal cal trachelectomy patients, noted that 43% of or intermenstrual bleeding (17%), problems women with tumors less than 20mm in diam- stenosis, scarring and/or dyspareunia follow- patients had attempted pregnancy and that with cervical sutures (14%), excessive vagi- eter and with invasion of less than 10mm16. Stretching had a second trimester miscarriage, 21% deliv- Posttrachelectomy, in the absence of adverse median age as 31 years and median follow- of tissues due to dilator therapy may reduce ered in the third trimester before 36 weeks, prognostic factors, patients are advised to use 27 up time of 48 months (1–176 months). The overall recurrence rate was reported as ity of aftercare, which may vary greatly from rospective review of 72 patients treated from If prognostic factors such as positive lymph 17 4. In this study, the rate of frst trimester ment in the form of radical hysterectomy or Radical abdominal trachelectomy team looking after trachelectomy patients. Such additional therapy population (16%), as was the rate of second should be undertaken at a suitable postopera- Some 116 patients have undergone radical trimester miscarriage (4% vs 3–5%). In their tive time which is usually 4–6 weeks postop- abdominal trachelectomy in published studies Fertility and miscarriage series, 72% were able to carry their pregnan- eration12. All trachelectomy cases require close worldwide which also report two recurrenc- cies to the third trimester and, of these, 78% gynecological oncology follow-up at 3 monthly es13. It was also noted that patients with rupture of membranes is acceptable to the requisite bodies of differ- and pelvic lymphatic tissue resection with the infertility secondary to cervical causes or ovu- ent nations12. Consideration of pregnancy dur- abdominal approach may contribute to high latory dysfunction had a reasonable chance The increased risk of preterm delivery may be ing this follow-up period should be in liaison levels of disease free survival rates18. However, it has been ment of cervical incompetence and preterm radical trachelectomy are performed via a clas- six of the seven preterm births were preceded suggested in one study that expectant man- labor should take the lead in managing these sical incision in order to prevent extension of by spontaneous rupture of membranes with- agement is a reasonable option until 32–34 women. This is similar to a series by Obstetricians should also stringently aim weeks of pregnancy in patients with prema- ered an optimal time for elective delivery13. Expect- to a minimum and cervical cytology should Postnatal follow-up ant management was carried out and all four probably be avoided beyond the frst trimes- women delivered within 4 days, three showing ter23. Cessation of coitus is advisable between Management of miscarriage No data suggest that pregnancy affects the can- signs of infection at the time of delivery25. Following delivery, the patient The etiology of premature rupture of mem- If frst trimester miscarriage occurs, expectant length may be followed up by serial vaginal 36 is advised to follow-up with her routine oncol- branes is thought to be either mechanical or ultrasounds. In the series of Since Actinomyces have been associated with general population, progesterone supposito- tion zone and suspicion of glandular neoplasia Bernardini et al. Two types of treat- mester loss delivered after removal of cerclage the authors recommended that anaerobic cul- posttrachelectomy as they appear to signif- ment are used for management of preinvasive and induction with misoprostol25. In Routine prophylactic steroids to accelerate dures include laser ablation, cryotherapy and patients who undergo radical trachelectomy, fetal lung maturity are recommended in view diathermy.

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Thus buy arava with american express medicine 3604 pill, knowing something about the characteristics of the test you are employing buy arava 20mg with amex treatment 0 rapid linear progression, and how to apply them to the patient at hand is essential in reach- ing a correct diagnosis and avoid falling into the common trap of “positive test = disease” and “negative test = no disease purchase 20mg arava mastercard medications i can take while pregnant. Nomogram illustrating the relationship between pretest probability, posttest probability, and likelihood ratio. Approach to Clinical Problem Solving There are typically four distinct steps to the systematic solving of clinical problems: 1. Experienced clinicians often make a diagnosis very quickly using pattern recognition, that is, the features of the patient’s illness match a scenario the physician has seen before. If it does not fit a readily recognized pattern, then one has to undertake several steps in diagnostic reasoning: 1. The clinician should start considering diagnostic possibilities with initial contact with the patient which are continually refined as information is gathered. Historical questions and physical examination tests and findings are all pursued tailored to the potential diagnoses one is considering. The next step is to try to move from subjective complaints or nonspecific symptoms to focus on objective abnormalities in an effort to conceptualize the patient’s objective problem with the greatest specificity one can achieve. For example, a patient may come to the physician complaining of pedal edema, a relatively common and nonspecific finding. Laboratory testing may reveal that the patient has renal failure, a more specific cause of the many causes of edema. Examination of the urine may then reveal red blood cell casts, indicating glomerulonephritis, which is even more specific as the cause of the renal failure. The patient’s problem, then, described with the greatest degree of specificity, is glomerulonephritis. The clini- cian’s task at this point is to consider the differential diagnosis of glomeru- lonephritis rather than that of pedal edema. This means the features of the illness, which by their presence or their absence narrow the differential diagnosis. This is often difficult for junior learners because it requires a well-developed knowledge base of the typical features of disease, so the diagnostician can judge how much weight to assign to the various clinical clues present. For example, in the diagnosis of a patient with a fever and productive cough, the finding by chest x-ray of bilateral apical infiltrates with cavitation is highly discriminatory. There are few illnesses besides tuberculosis that are likely to produce that radi- ographic pattern. A negatively predictive example is a patient with exuda- tive pharyngitis who also has rhinorrhea and cough. The presence of these features makes the diagnosis of streptococcal infection unlikely as the cause of the pharyngitis. Once the differential diagnosis has been con- structed, the clinician uses the presence of discriminating features, knowl- edge of patient risk factors, and the epidemiology of diseases to decide which potential diagnoses are most likely. Looking for discriminating features to narrow the differential diagnosis Once the most specific problem has been identified, and a differential diag- nosis of that problem is considered using discriminating features to order the possibilities, the next step is to consider using diagnostic testing, such as labo- ratory, radiologic, or pathologic data, to confirm the diagnosis. Quantitative reasoning in the use and interpretation of tests were discussed in Part 1. Clinically, the timing and effort with which one pursues a definitive diagnosis using objective data depends on several factors: the potential gravity of the diagnosis in question, the clinical state of the patient, the potential risks of diagnostic testing, and the potential benefits or harms of empiric treatment. For example, if a young man is admitted to the hospital with bilateral pul- monary nodules on chest X-ray, there are many possibilities including metastatic malignancy, and aggressive pursuit of a diagnosis is necessary, perhaps includ- ing a thoracotomy with an open-lung biopsy. The same radiographic findings in an elderly bed-bound woman with advanced Alzheimer dementia who would not be a good candidate for chemotherapy might be best left alone with- out any diagnostic testing. Decisions like this are difficult, require solid med- ical knowledge, as well as a thorough understanding of one’s patient and the patient’s background and inclinations, and constitute the art of medicine. Some diseases, such as congestive heart failure, may be designated as mild, moderate, or severe based on the patient’s functional status, that is, their ability to exercise before becoming dyspneic. With some infections, such as syphilis, the staging depends on the duration and extent of the infection, and follows along the natural history of the infection (ie, primary syphilis, secondary, latent period, and tertiary/neurosyphilis). If neither the prognosis nor the treat- ment was affected by the stage of the disease process, there would not be a reason to subcategorize as mild or severe. In making decisions regarding treatment, it is also essential that the clinician identify the therapeutic objectives. When patients seek medical attention, it is generally because they are bothered by a symptom and want it to go away. When physicians institute therapy, they often have several other goals besides symptom relief, such as prevention of short- or long-term complications or a reduction in mortality. For example, patients with congestive heart failure are bothered by the symptoms of edema and dyspnea. Salt restriction, loop diuretics, and bed rest are effective at reducing these symptoms. It is essential that the clinician know what the thera- peutic objective is, so that one can monitor and guide therapy. Clinical Pearl ➤ The clinician needs to identify the objectives of therapy: symptom relief, prevention of complications, or reduction in mortality. Some responses are clinical, such as the patient’s abdominal pain, or temper- ature, or pulmonary examination. Obviously, the student must work on being more skilled in eliciting the data in an unbiased and standardized manner. The stu- dent must be prepared to know what to do if the measured marker does not respond according to what is expected. Is the next step to retreat, or to repeat the metastatic workup, or to follow up with another more specific test? Approach to Reading The clinical problem–oriented approach to reading is different from the clas- sic “systematic” research of a disease. Patients rarely present with a clear diag- nosis; hence, the student must become skilled in applying the textbook information to the clinical setting. In other words, the student should read with the goal of answering specific questions. Clinical Pearl ➤ Reading with the purpose of answering the seven fundamental clinical questions improves retention of information and facilitates the application of “book knowledge”to “clinical knowledge. One way of attacking this problem is to develop standard “approaches” to com- mon clinical problems. It is helpful to understand the most common causes of various presentations, such as “the most common causes of pancreatitis are gallstones and alcohol. With no other information to go on, the student would note that this woman has a clinical diagnosis of pancreatitis. Using the “most common cause” information, the student would make an educated guess that the patient has gallstones, because being female and pregnant are risk factors. If, instead, cholelithiasis is removed from the equation of this scenario, a phrase may be added such as: “The ultrasonogram of the gallbladder shows no stones. Now, the student would use the phrase “patients without gallstones who have pancreatitis most likely abuse alcohol. This question is difficult because the next step may be more diagnostic infor- mation, or staging, or therapy. It may be more challenging than “the most likely diagnosis,” because there may be insufficient information to make a diagnosis and the next step may be to pursue more diagnostic information.