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Compare the following lists: complete fill in achieve do maintain keep up compile put together 252 WRITING SKILLS IN PRACTICE Doctors whose communication skills are poor upset the clients order 25 mg clomid fast delivery. For ex­ ample: ° ‘imply’ (suggest) versus ‘infer’ (deduce) ° ‘practical’ (pragmatic) versus ‘practicable’ (feasible) ° ‘less’ (quantity) versus ‘fewer’ (number) buy generic clomid 50mg on line. General writing pitfalls Here are some common pitfalls that catch most writers out at some point buy clomid 100 mg on line. DETERMINING YOUR STYLE 253 Summary Points ° Find your style by using your natural ‘voice’ when writing clomid 25mg without prescription. Revisions are far easier with many writing tasks au­ tomated, for example checking spelling and grammar, doing word counts. Computers with a modem also offer another mode of communication via e-mail and access to research material on the Internet. This chapter offers an introduction to making the most of your com­ puter as an author. Organising your work File your work Create individual files for the chapters or sections of your book. Keep these in one or more folders so that you can easily locate your work. Check with your publisher’s guidelines about any limits on the size of files. Database A database is a program that helps organise information in a similar way to a manual card index. Information such as names, addresses, dates and titles is entered onto individual records. Each of these records has a number of allotted spaces, known as fields, which contain the individual data entry. For example, one field might have the name, while another has the address. For in­ stance, the records can be sorted to appear alphabetically, or a search car­ ried out for all records containing the same name. A database is particularly useful for compiling bibliographies or reference lists. There are two types of memory: ° Random Access Memory (RAM) – this is the memory your computer uses to hold the text, graphics and instructions that you input as you are working on a document. This is why you need to make sure you have saved your work, either to the hard disk (usually ac­ cessed through drive C) or onto a floppy disk (accessed through drive A). Memory is measured in megabytes (Mb) and this is usually quoted in any specifications about a computer. It is important to check that you have sufficient memory to run the programs and store the amount of informa­ tion you require. For example, if you saved your work every 20 minutes, then this is the maximum amount of work you would lose if the computer crashed. Some computers have a fa­ cility where the file is automatically saved at regular time intervals. Frequent saves mean less work will be lost if the com­ puter suddenly crashes. Disks Back up your work regularly by copying the latest version of your work onto a floppy disk. It is best to have at least two back-up disks and keep these in separate places. Find a suitable container to store them in, which will keep them free from dust and accidental damage. Identify your current disk clearly, so that it is easily distinguishable from your back-up floppies.

The more complex multiple type (also know as the cluster type) is very popular because it allows a series of questions to be asked relating to a single stem or topic order clomid 100 mg fast delivery. However clomid 50 mg for sale, the questions may also be considered as a group with full marks given only if all the questions are correct and part-marks given if varying proportions of the questions are correct purchase clomid 100mg on-line. Research has shown that the ranking of students is unaltered by the marking scheme used purchase clomid 50 mg free shipping, so simplicity should be the guiding principle. Multiple-choice questions An example of a simple multiple-choice question (MCQ) is shown in Figure 8. The MCQ illustrated is made up of a stem (‘In a 40 year old’) and five alternative answers. Of these alternatives one is correct and the others are known as ‘distractors’. One advantage of the MCQ over the true-false question is a reduction in the influence of guessing. Obviously, in a simple true-false question there is a 50 per cent chance of guessing the correct answer. In a one from five MCQ there is only a 20 per cent chance of doing so if all the distractors 143 are working effectively. Unfortunately it is hard to achieve this ideal and exam-wise students may easily be able to eliminate one or two distractors and thus reduce the number of options from which they have to guess. Information about the effectiveness of the distractors is usually available after the examination if it has been computer-marked. Some advocate the use of correction formulas for guessing but this does not – on balance - appear to be worth the effort and may add an additional student-related bias to the results. If you intend to use multiple-choice questions you should take particular note of the points in Figure 8. It is possible to develop questions with a more complex stem which may require a degree of analysis before the answer is chosen. Such items are sometimes known as context-dependent multiple-choice questions. One or more multiple-choice questions are based on stimulus material which may be presented in the form of a clinical scenario, a diagram, a graph, a table of data, a statement from a text or research report, a photograph and so on. This approach is useful if one wishes to attempt to test the student’s ability at a higher intellectual level than simple recognition and recall of factual information. Extended-matching questions The technical limitations of conventional objective-type items for use in medical examinations has stimulated a search for alternative forms which retain the technical advantages of computer scoring. Many such efforts have achieved little more than increasing complexity and confusion for students. However, the extended matching question (EMQ) is becoming increasingly popular. The main technical advantage is the reduced impact of cueing by increasing the number of distractors. Other advantages include ease of construction and flexibility as they work equally well for basic science as for clinical areas. However, they are particularly well suited for testing diagnostic and management skills. The EMQ is typically made up of four parts: a theme of related concepts; a list of options; a lead-in statement to direct students; and two or more item sterns. The item shown includes two stems that illustrate how this EMQ might test at different levels. The first stem requires problem solving in order to determine a diagnosis; the second stem tests only recall. More stems could, of course, be added to this example to increase the content coverage of the test item and the range of levels tested. In some respects, EMQs share similarities with the context- dependent MCQ we described earlier.

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This may be due to poor posture or other improper body movements cheap 50mg clomid with amex, such as sit- ting at a computer all day or talking with the telephone cradled between your head and shoulder generic 100mg clomid with amex. In women 50mg clomid with mastercard, it can be caused by constantly carrying heavy purses over the shoulders order clomid 25 mg with visa, and in men, it can result from sitting on a wallet. Hormones communicate broadly with other organs through the nervous system, cytokines (proteins that regulate the immune system), and growth factors. Endocrine disorders often cause imbalances in metabolism and as such are among the most difficult to diagnose; the metabolic system as a whole is a finely integrated network of an infinite number of chemical reactions occurring in all body cells, coordinated by signal systems such as hormones and enzymes. Common endocrine disorders include diabetes and other pan- creatic disorders and pituitary, adrenal gland, and thyroid disorders. One metabolic condition in children that has only recently been identified was for many years believed to be the result of deliberate “bad” behavior and thus psychological in origin. Today we know that bedwetting is actually a metabolic disorder and can be treated successfully with a nose spray at bed- time that replaces the hormone necessary for regulating the reabsorption of water in the kidneys. Examples are fractures, sprains, dislocations, head trauma, eye injuries, and tooth loss. Case Studies: Kara and Don Kara suffered for years from vaginal discharge and dyspareunia (pain with sex). Her gynecologist was perplexed by the persistence of erosions (sores) on her cervix despite numerous attempts at therapy, including antibiotics, antifungals, cauteri- zation, and even partial excision (removal of the cervical wall). Only years later, after doing research on the Internet, did Kara realize that she had been inserting her diaphragm upside down, resulting in chronic irritation (trauma) of her cervix. Another case study is Don, who suffered from poor vision for a number of years. He was eventually diagnosed with keratoconus, an unusual cone formation of the cornea. By following the Eight Steps, he sharpened his powers of observation and discovered he was inflicting this condition on himself by consistently rubbing his eyes with a turning motion (trauma). The Eight Steps to Self-Diagnosis 51 Because the word trauma implies a stressful injury requiring emergency treatment, it is easy to ignore the possibility that more subtle problems can also have their origins in a traumatic injury. In the age of modern med- icine we have some wondrous treatments and cures, but they can sometimes inflict a heavy penalty. Some iatrogenic effects are unavoidable and consid- ered reasonable; they are known, expected, and endured because the bene- fits of the treatment outweigh the negative side effects. As medical mysteries abound and solutions become even harder to come by, and as drug companies market aggressively and governmental reg- ulations become more lax, growing numbers of doctors and their patients are experimenting with “off-label” medication use (prescribing medications for something other than their approved purposes). A recent study showed that more than 115 million such prescriptions were written in one year (2003) and thousands of patients have suffered serious, permanent, and mysterious iatrogenic consequences. Also, there are documented cases of mistakes by overworked nurses and physicians, foreign sales of unauthorized drugs, self-treatment by patients, and an increase in elective surgeries and treatments to consider. All these factors can create medically induced conditions; unfortunately, most are not necessarily recognized as such. Do a careful analysis of every medical intervention (physical therapy, medications, procedures, supplements, or treatments of any kind) you’ve had to determine if a possible relationship exists between the cause of your symptoms and that intervention. Recently, after years of use, Ephedra—a *For example, the use of glucocorticoids (steroids, prednisone, cortisone) to control progres- sive immunological, hematological, or neurological conditions may produce side effects like truncal obesity, buffalo hump, stretch marks, fragile and thin skin, easy bruising, elevated blood sugar, and a rounded face. Surgeon General reflect the view that mental health and psychological illnesses are really just points along a continuum. For this reason, illnesses that are psychological in origin are difficult to iden- tify. That, together with the fact that many such illnesses have very real phys- ical or bodily symptoms, makes it easy to understand why they are often at the root of mystery maladies. So do not rule out this potential source of your mystery malady until you’ve investigated it fully. Step Seven: Investigate Your Lifestyle and Belief System Sometimes a person’s lifestyle and beliefs must be examined in order to arrive at a correct diagnosis.

Singer Departments of Neurology and Pediatrics generic clomid 50 mg without prescription, Johns Hopkins University School of Medicine discount 100 mg clomid mastercard, Baltimore generic 100 mg clomid otc, Maryland buy 25 mg clomid with mastercard, U. OVERVIEW The Gilles de la Tourette syndrome (TS) is a chronic, inherited neuropsychiatric dis- order characterized by the presence of involuntary motor and phonic tics that wax and wane. Although once considered a rare disorder, the prevalence of TS may be as high as 3. In addition to tics, individuals with TS often have a variety of concomitant psychopathologies including obsessive compulsive dis- order (OCD), attention deficit hyperactivity disorder (ADHD), learning difficulties, and sleep abnormalities. Although the presence of neurobehavioral problems is not required for the diagnosis of TS, their clinical impact on the patient may be more significant than the tics themselves. Tourette syndrome is an inherited disorder (spe- cific gene and mode of inheritance remain unclear), but nongenetic environmental factors can influence tic frequency and severity. Pathophysiologically, tics arise within cortico-striatal-thalamo-cortical pathways and likely represent a dysfunction of synaptic neurotransmission. Diagnosis Formal diagnostic criteria include: (a) onset of symptoms before age 21; (b) the pre- sence of multiple motor and at least one vocal tic (not necessarily concurrently); (c) a waxing and waning course, with tics evolving in a progressive manner; (d) the presence of tic symptoms for at least 1 year; (e) the absence of a precipitating illnesses (e. Tics, the essential component of the syndrome, are manifest in a variety of forms, with different durations and degrees of complexity. Common characteristics of tics include: brief voluntary suppression; exacerbation by anxiety, excitement, anger, or fatigue; reduction during absorbing activities or sleep; and fluctuation over time. Premonitory urges or sensations, such as a tickle, itch, discomfort, or ‘‘feeling,’’ are reported in some TS patients before they make a tic movement or vocalization. Investigators used a mathematical model to assess the time course of tic severity over the first two decades, which suggested that maximum tic severity occurs between the ages of 8 and 12 years and is then followed by a steady decline in symptoms. In a study of 58 teenager=young adults, tics virtually disappeared in 26%, diminished considerably in 46%, remained stable in 14%, and increased in 14%. Early tic severity is not a good predictor of later tic severity, but some authors have suggested that the presence of only mild tics through adolescence was a good indicator of mild tics in adulthood. Nevertheless, even cases with severe tics in childhood had the potential for a good outcome. EVALUATION AND EDUCATION Although approaches to the assessment and treatment of individuals with TS may vary, there are several important steps (Table 1). All patients with tics should be evaluated to assure the proper diagnosis and to eliminate the possibility that tics are secondary to another medical condition. Personal interview of the patient and parent and the use of standardized parent=teacher questionnaires are helpful in iden- tifying the presence of comorbid psychopathology and academic problems. Further, it is essential to identify the level of adaptive functioning, degree of impairment, and extent of distress associated with tics and with each comorbid condition. The physi- cian should educate the patient and family about the characteristics of the disorder, that tics wax and wane, have periodic fluctuations, and are variable. It should be emphasized that tics are involuntary and not secondary to stress or an underlying psychological problem. The effect of environmental factors should be clarified and the controversial role of infection noted. The purpose of symptomatic therapy must be carefully reviewed, and its goals of targeting specific symptoms defined. Finally, physicians must emphasize that they are there to provide long-term treatment. TREATMENT Treatment is individualized on the basis of the functional impairment resulting from tics and=or comorbid problems, sources of support, capacities for coping, and challenges associated with various stages of development. Medications should Table 1 General Principles for Evaluation of Patient with Tics (1) Document tics (2) Take history and perform physical examination (3) Assess for comorbid psychopathology and academic problems (4) Identify degree of impairment and extent of distress for tics and each comorbid condition (5) Educate the patient and family (6) Establish consensus about need for treatment (7) Discuss available therapy (8) Emphasize your availability to provide long-term treatment Treatment of Tourette Syndrome 127 Table 2 Treatment Decisions General 1. Define what symptoms require pharmacotherapy If tics are causing significant psychosocial or physical problems, consider Rx 3. Remember, tic-suppressing medications do not generally treat comorbid issues 4. A conservative approach is recommended Observation or nonpharmacologic be targeted and reserved for only those problems that are functionally disabling and not remediable by nondrug interventions. For many families, education about the diagnosis, outcome, genetic predisposition, underlying pathophysiologic mechanism, and availability of tic-suppressing pharmacotherapy often obviate or delay the need for medication.

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