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The information is compiled into a list by a person external to the panel 100mg suhagra free shipping erectile dysfunction herbal medications, who marks any items that have not received unanimous support purchase 100 mg suhagra amex erectile dysfunction facts. The list is returned to the ex­ perts who are asked to comment (again anonymously) on the items not agreed generic suhagra 100 mg with amex erectile dysfunction age statistics. The process is repeated until there is a core list of items that everyone agrees upon. Use a storyboard A storyboard is a way of planning the sequence of your information. Using a simple grid, the planned content is plotted out like a story using simple bullet points or summaries. This gives you a clearer idea of the order and provides an overview that is difficult to get in any other way. Your instinct may be to follow the medical model and start with a description of the disease, causes, treatment and so on. However, this might not be the way in which the client experiences his or her illness. Explain terminology It may be necessary to use certain terms and expressions. Always make sure you give an explanation, and if necessary provide examples. In the follow­ ing extract, the term ‘urethra’ is explained in simple language. The prostate is a small gland, which lies at the neck of the bladder in men and surrounds the urethra – the tube that carries urine from the bladder to the penis …’ (World Cancer Research Fund 2000) Once you have explained a label, continue to use it rather than introducing any alternatives. Be aware of ambiguous word meanings In English some of the words we use alter in meaning depending on the context in which they are used. Look at the examples below: ° Registrar = ° In the registry office – a keeper of names for births, deaths and marriages. Make sure that your reader will understand the intended meaning of your vocabulary. Check the emotional loading of words Certain words will have a higher emotional loading for clients. For exam­ ple, the words ‘cancer’ and ‘treatment’ in a recall letter after breast screen­ INFORMATION LEAFLETS FOR CLIENTS 99 ing were found to make women worry (Austoker and Ong 1994). Rewording the message may reduce stress and anxiety – so using ‘most re­ called women are found to have normal breasts’ was more reassuring than ‘most recalled women are found not to have cancer’ (Ong, Austoker and Brouwer 1996). Write words in full Avoid using abbreviations or acronyms even if these are explained in your text. They tend to confuse readers who are less familiar with these types of expressions. Phrasing the message The type and length of sentences will affect the amount of information the reader understands and remembers. Use short words and sentences There are a number of published tests designed to calculate the readability of set pieces of text (Flesch 1948; Gunning 1952). These make their calcu­ lations using various formulae that involve looking at the length of sen­ tences and the number of syllables. These tests predict the reading age required to cope with decoding the text. They are of use in checking the readability of your text but are not fail-safe ways of establishing how easy your text is to read. Use short words and sentences as this helps under­ standing and recall of information in written information (Ley 1982). Write sentences in the active rather than the passive voice Active sentences are more direct and give impact to a message. Compare the following sentences: ‘Tooth decay is prevented by regularly brushing the teeth’ (passive). Compare the following: Empowerment give choices, take control, make decisions Episodes of care your stay in hospital, the period of your therapy Partnership working together. The use of vocabulary that requires the reader to make some sort of judgement is best avoided. For example, in the sentence, ‘Make sure you have an adequate fluid intake’, the reader is ex­ pected to estimate the value of ‘adequate’. The sentence might be better phrased as ‘drink six glasses of water a day’. Other examples are ‘excessive bleeding’, ‘severe pain’, ‘small discharge’ or ‘enlarged gland’. Rephrase the statements so they give the reader informa­ tion about how to measure these things. Be succinct Remove any words that are superfluous to the meaning of the sentence. For instance ‘one pill every day of the week’ might be rephrased as ‘a pill daily’. For example, ‘nine out of ten people make a complete recovery’ is better than ‘one in ten people die’. Increasing comprehension of the message The way in which you phrase your message will affect how easy it is for the reader to understand the information. Use simple sentence constructions Simple sentences have more content words like nouns, verbs and adjectives that give the reader specific information. Avoid using complex sentences containing lots of small grammatical words that are not strictly necessary INFORMATION LEAFLETS FOR CLIENTS 101 to the meaning. For example, ‘You should eat up to about five portions of fruit and vegetables in a day’ is easily converted into the simple and well-known phrase, ‘Eat five portions of fruit and vegetables a day’. State the context first In the following sentence the key message is about low fat foods: ‘Vegetables and fruit are low fat foods. Place ‘low fat foods’ at the beginning, and the reader has a meaningful context in which to place the following list of foods. For example, give the client a list of low fat foods and ask them to circle the ones they already eat. Next, ask them to write out the names of the foods that they were unaware were low in fat. Ask them to choose, from this list, foods they would like to start eat­ ing. Get them to divide the list into completely new items and ones that could be used to replace a high fat food they currently consume. By help­ ing the client to recognise familiar foods and highlighting new ones, you are helping them assimilate the information into their knowledge base. Engaging the reader Like any piece of written work, your leaflets need to attract and maintain the reader’s interest. You need to phrase your message in a way that is ap­ pealing and meaningful for the reader.

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Step One: Record the Exact Nature of Your Symptoms In this step buy suhagra 100mg low cost jack3d causes erectile dysfunction, you’ll be creating and keeping a notebook that will be used for all the remaining steps buy suhagra 100 mg free shipping what if erectile dysfunction drugs don't work. In this notebook purchase suhagra 100mg with amex do herbal erectile dysfunction pills work, you will begin to record and doc- ument your own medical case. You’ll be compiling a detailed list of all the symptoms and signs of your mystery malady, using the detailed questions given. We recommend using a three-ring loose-leaf notebook rather than a spiral-bound one, because the better you become at detecting, the more likely you will be to return and add material (pages) to earlier parts of your notebook. In order to record your symptoms, we first need to define signs and symptoms and understand the difference between them. Symptoms Versus Signs Medical textbooks describe symptoms as any perceptible change in the body or its functions that signals disease or phases of disease. A symptom is a sen- sation that only you can perceive and is normally not measurable (like pain 38 Becoming Your Own Medical Detective or fatigue). A sign is an indication of illness that’s actually observable and measurable (like a rash or a fever). For our purposes, it’s irrelevant whether the bodily change is subjective (symptom) or objective (sign). In observing and recording your symptoms, we urge you not to over- look any bodily change, no matter how insignificant it may seem to you. Be as objective and factual as possible, but bear in mind that your objectivity may be compro- mised by your own unconscious feelings about being ill. Most people are afraid of disability, loss of independence, and, of course, ultimately death. Even if we are not consciously aware of these feelings, our fears may distort our perceptions, causing us to magnify or minimize our symptoms. Case Study: Tim Consider Tim, a mystery malady patient, whose hands and knees were swollen. He described his fingers as sausages—a big problem since he was required to use a com- puter keyboard at work. He was diagnosed with arthritis but was unable to gain any relief from the resulting treatment. We asked him to begin working through our self-diagnosis model by making a detailed list of all his symptoms. As he answered the questions in each of the Eight Steps, he sharpened his thinking and found himself regularly returning to his notebook to add more symp- toms. On his fourth return to Step One, he listed a symptom that had been present since the onset of his swollen fingers. He hadn’t included it previously because it seemed to be an unrelated condition—scaly, white, dandruff-like patches of skin on both elbows. She told him she also had this hereditary condition, diagnosed as psoriasis. Tim returned with his symptom list to the physician who had originally diag- nosed the swelling in his fingers and knees as arthritis. When he brought all his symptoms to the doctor’s attention, she immediately made a connection: Tim prob- ably had a rare form of arthritis known as psoriatic arthritis. When the psoriasis that actually causes the arthritis is treated aggressively, the arthritis improves. His case shows that even the smallest, seemingly irrel- evant symptom can be a clue that leads to a diagnostic solution. Anxiety over the possibility of disability can make us engage in catastrophic thinking, to perceive our symptoms as far worse than they really are. Conversely, some of us may be so afraid of becoming disabled that we defend against this fear by trying to minimize our symptoms, maybe even to the point of denying they exist or the degree to which they exist. Being aware of these possible subconscious feelings will help you evaluate whether or not you are accurately recording your symptoms. For example, if your major symptom is stomach pain, narrow it down further. For example, is the pain in the lower left quadrant, just under the navel, or in the upper right side under the breastbone? Make a separate section in your notebook for each of the following categories: • Quality and Character. Continuing with our example of stomach pain, is the pain best described as a dull ache or a sharp, shooting pain? On a scale of one to ten, what number would you assign to your level of discomfort or pain? If pain is one of your symptoms, it is helpful to use a 1–10 scale to characterize it. Then you can rate it as a “3” in the morning and a “10” at night, for example. For example, does stomach pain happen after you eat or at a certain time of day? Where do your symptoms usually occur— in certain climates, in certain locations, at high or low altitude, at high or low barometric pressure, in sun or shade, or during periods of intense stress? As soon as she allowed herself to acknowledge how angry she was about a particular life situation, she made the necessary change and miraculously her infections resolved. Karen’s infections were not psychosomatic; on the contrary, they had been objectively documented by urine cultures. However, it is entirely possible that resolv- ing her anger released the tension she had been carrying in her body. Once her ure- thra became more relaxed, it allowed an uninterrupted flow of urine and a more complete emptying of her bladder. The less urine retained in her bladder, the less likelihood of the urine becoming infected. While you’re experiencing the symptom, must you stop what you are doing, or can you continue your activities? Do you have any other thoughts, intuitions, or “gut feelings” about your symptoms? This is not about being right or technically correct but about keeping an open mind while you explore your mystery malady. Step Two: Think About the History of Your Mystery Malady How long you have been having symptoms and when you first began hav- ing them are very important clues. For example, it is impossible to experience painful “gout” attacks that last for months because gout is a self-limiting disease, meaning that it evolves and resolves over the course of days (with or without treatment). If what you think is gout doesn’t go away after a week or so, it’s likely not that.

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The leader sutures from the ends of the tendons are tied over a periosteal button to augment the tibial screw fixation (Fig suhagra 100 mg for sale erectile dysfunction pills wiki. Graft Inspection: Look and Hook The graft is inspected as the knee is moved through a range of motion purchase 100mg suhagra free shipping erectile dysfunction hypogonadism, looking for anterior impingement and lateral wall abrasion (Fig order suhagra 100 mg erectile dysfunction due to drug use. KT-S Measurements Before the sutures are cut, the KT-S is used to pull a manual maximum number. Generally the manual maximum a-p translation will be equal or 1 to 2mm less than the opposite side (Fig. One common problem is when the tibial screw pushes the graft up the tunnel. The surgeon must maintain firm distal traction on the leader sutures to prevent the screw from grafting up. The sutures are cut off when the surgeon is satisfied that the knee is stable and the fixation is secure. Postoperative Regimen: Extension Splint, Cryo-Cuff, and Continuous Passive Motion Machine After the wounds are closed, the author applies a Tegaderm (Sklar Instruments, West Chester, PA) dressing, a compressive stocking and the Cryo-Cuff (Aircast, Summit, NJ) (Fig. This is a sleeve that contains cool water and lowers the temperature of the knee, thereby reducing the pain. The patient is transferred to a continuous passive motion (CPM) machine and to the recovery room (Fig. When the patient gets up, he/she use the extension splint and crutches (Fig. The patient goes home several hours postoperatively with the CPM, the Cryo-Cuff, the extension splint, and crutches. The Tegaderm dressing is removed, and the Cryo-Cuff applied directly to the skin. The wounds are cleansed for the next few days with 3% hydrogen peroxide. The author has a proto- col that can be mailed to remote physiotherapy locations to ensure that the early extension routine is started. The physician should try to get KT- 1000 measurements at 6 weeks and at 3, 6, and 12 months. If there is any loss of extension, this is addressed early by vigorous aggressive reha- bilitation. If there is still loss at three months, surgical debridement is suggested. Crutches and an extension splint are used for the first few days postoperative when ambulating. Some of the prepration for the procedures described in this chapter is the same as for the procedures discussed in Chapter 6. EUA, KT-1000 Measurements, Joint Injection, and Femoral Nerve Block First confirm which is the correct side. The low profile leg holder is high on the thigh to allow the graft passing wire to penetrate the anterolat- eral thigh. Preemptive Pain Management In a recently published paper, we documented the benefit of the pre- emptive use of the femoral nerve block, intravenous injections, and local knee injections. The knee joint and the incisions are injected with 20cc of bupivacaine 0. The patient has taken 50mg of Vioxx orally one hour before, and the anesthetist gives 1gm Ancef intravenously. The author uses a Linvatec (Largo, FL) fluid pump that works in coordination with the Apex driver system for the shaver and burrs to coordinate the flow level. Diagnostic, Operative Arthroscopy The diagnostic arthroscopy should be done before the graft harvest if there is any doubt about the diagnosis of partial versus complete ACL tear. The video on the CD illustrates this process, as well as the inside view of the “W,” as dis- cussed in Chapter 2. Diagnostic, Operative Arthroscopy 123 The ACL must be carefully examined. The conventional wisdom is that a tear more than 50% should be reconstructed. But a partial tear, one of less than 50%, may have to be reconstructed with a patellar tendon. If the tear is minimal, with a negative pivot shift, this patient should be treated conservatively. A complete diagnostic arthroscopy should be performed before any meniscal work is done. This ensures that the physician will not forget the lateral compartment if a lot of time is required to perform menis- cal repair on the medial side. In young patients, every attempt should be made to repair the meniscus rather than resect it. The long-term results of reconstruc- tion are more related to the state of the meniscus than to the stability. A flap tear of the meniscus will cause pain, swelling, catching and giving way (Fig. The flap is easily resected with a basket forceps and a motorized shaver. In young patients, the surgeon should make every attempt to repair the meniscus rather than resect it. The long-term results of reconstruction are more related to the state of the meniscus than to the stability. The debate is whether to repair the meniscus and do the ACL reconstruc- tion at the same sitting. If the limita- tion of extension is mild, the patient is weight bearing and the graft choice is hamstrings, the meniscus repair and ACL reconstruction can be done in one sitting. If the patient is on crutches with a significant lack of extension, for example 40°, the procedure should be staged to avoid postoperative stiffness. The meniscus repair is carried out, and when the patient has regained full range of motion, an ACL reconstruction is done. For the management of the associated meniscus pathology, see the hamstring graft, described in Chapter 6. Graft Harvest and Preparation The longitudinal incision should be 8 to 10cm long and 1cm medial to the tendon. The surgeon should plan for the lower end to incorporate the tibial tunnel. The incision can be as short as 5cm if cosmetic appearance is important. The author has used two separate transverse Graft Harvest and Preparation 125 incisions in the past, but prefers, in a teaching situation, to use the lon- gitudinal incision. Studies have shown that the two transverse incisions do not injure the infrapatellar branch of the nerve, and the patients are able to kneel after the patellar tendon harvest.

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