CHIEF COMPLAINT by L75o9l

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									  DISCLOSURE: F.FITZGERALD
           M.D.
I HAVE NOT BEEN BRIBED
I HAVE NOT BEEN CORRUPTED
I HAVE NO HIDDEN ALLIANCES
  WITH RICH PEOPLE
MY MOTIVES ARE PURE
MAGICAL    MEDICAL
  HISTORY TOUR

   WHO IS THE PATIENT?
  WHAT IS THE DIAGNOSIS?
MORE AND BETTER TO FOLLOW!
    CHIEF COMPLAINT
     A 29 YEAR OLD ENGLISH
    AUTHOR HAD A PAIN IN HIS
             BUM*




*ENGLISH ‘BUM’=AMERICAN ‘BUTT’
 HISTORY OF PRESENT ILLNESS
HE HAD SUFFERED FOR MANY YEARS
  FROM RECTAL PAIN, WHICH BOTH
  HE AND HIS SURGEON ATTRIBUTED
  TO TOO MUCH SITTING.
HIS DISORDER WAS COMMON AMONG
  OTHERS WHOSE OCCUPATION HAD
  THEM SITTING A LOT, INCLUDING
  TAILORS: THEY ACTUALLY FORMED
  CLUBS TO COMMISERATE WITH
  EACH OTHER.
HISTORY OF PRESENT ILLNESS
ABOUT 150 YEARS BEFORE OUR
 PATIENT’S PAIN, THE “SUN
 KING”, LOUIS XIV OF FRANCE,
 HAD A SIMILAR PAIN WHERE
 THE SUN DIDN’T SHINE.
HIS SURGEON ,FELIX de TASSY,
 PERFECTED AN OPERATION,
 PRACTICING ON COMMONERS
 BEFORE DOING IT ON THE
 KING. THAT OPERATION
 REMAINS ESSENTIALLY
 UNCHANGED SINCE.
 HISTORY OF PRESENT ILLNESS
OUR PATIENT UNDERWENT SURGERY,
 WHICH WAS SO SUCCESSFUL THAT HE
 PERSUADED THE HEAD OF THE
 GUINNESS (STOUT) EMPIRE TO FUND A
 DISPENSARY FOR RELIEF OF THE POOR
 AFFECTED WITH SIMILAR PROBLEMS:
 THAT DISPENSARY TODAY IS ST MARK’S
 HOSPITAL, LONDON.
PAST, SOCIAL, FAMILY HISTORY
HIS FATHER WAS A CLERK IN THE
  NAVY PAY OFFICE, WENT DEEPLY
  INTO DEBT AND WAS PUT INTO
  DEBTORS ’ PRISON.
OUR PATIENT, AGE 12, HAD TO
  WORK IN A SHOE POLISH
  FACTORY. HE WAS HUMILIATED,
  BUT USED HIS EXPERIENCE OF
  POVERTY IN LATER NOVELS.
PAST, SOCIAL, FAMILY HISTORY
HE HAD TEN CHILDREN
HE WAS A VERY, VERY SUCCESSFUL WRITER AND
  ‘INVENTED’ THE SERIALIZED NOVEL.
HE READ AND ACTED OUT HIS NOVELS ON
  STAGE DURING ‘SPEAKING TOURS’, INCLUDING
  IN THE UNITED STATES.
HE DIED OF A STROKE, AGE 58, IN THE MIDST
  OF WRITING A NOVEL WHICH REMAINED
  UNFINISHED: ”THE MYSTERY OF EDWIN
 DROOD”.
PAST, SOCIAL, FAMILY HISTORY
HE IS BURIED IN WESTMINSTER ABBEY’S
           POETS’ CORNER.
      WHO WAS THE PATIENT?
       SOME FURTHER CLUES
HIS NICKNAME, TAKEN FROM AN EARLY SERIES
  OF SKETCHES HE WROTE, WAS “BOZ”.
IN HIS FIRST MONTHLY SERIALIZED WORK, HE
  DESCRIBED A FAT BOY WHO KEPT FALLING
  ASLEEP. FROM THIS CAME THE NAME OF A
  SYNDROME YOU KNOW AND STILL DIAGNOSE
  TODAY.
    A VERY GOOD CLUE INDEED.

IN A SHORT NOVEL
  ABOUT THIS




HE BEGAN WITH THE
  LINE “IT WAS THE
  BEST OF TIMES; IT
  WAS THE WORST OF
  TIMES.”
ANOTHER OF HIS FAMOUS STORIES
 WAS ABOUT THIS TIME OF YEAR
WHO WAS THE PATIENT?
                         FACE WIZARD




  1812            1870




     CHARLES DICKENS
   WHAT WAS THE DIAGNOSIS?
                                DX WIZARD




PERIANAL ABSCESS FROM FISTULA IN ANO



                        OUCH!
THE PATHOGENESIS OF PERIANAL
          ABSCESS
IF THERE’S MORE THAN ONE
FISTULA, THINK OF CROHN’S
         DISEASE
CHARLES DICKENS WROTE MANY
       GREAT THINGS
    THE PICKWICK PAPERS
IT IS FROM THIS THAT WE GET
  “PICKWICK SYNDROME’ TO
  DESCRIBE OBSTRUCTIVE SLEEP
  APNEA ASSOCIATED WITH
  OBESITY.
       A TALE OF TWO CITIES
“IT WAS THE BEST OF TIMES, IT WAS THE
WORST OF TIMES.
IT WAS THE AGE OF WISDOM, IT WAS THE
AGE OF FOOLISHNESS.
IT WAS THE EPOCH OF BELIEF, IT WAS THE
EPOCH OF INCREDULITY.
IT WAS THE SEASON OF LIGHT, IT WAS THE
SEASON OF DARKNESS.
IT WAS THE SPRING OF HOPE, IT WAS THE
WINTER OF DESPAIR…”
 IN A CHRISTMAS CAROL, THERE
IS A CHARACTER CALLED ‘MARLEY’S
            GHOST’
    THERE IS ANOTHER FAMOUS
     SPIRIT NAMED MARLEY…
BOB MARLEY,
 REGGAE MUSICIAN,
 WHO PLAYED AND
 SANG WITH HIS
 GROUP, THE
 WAILERS.
BOB MARLEY DIED AT AGE 36 OF
    “CANCER OF THE TOE”




   METASTATIC ACROLENTIGINOUS MELANOMA
 (OTHER KINDS OF MELANOMA)
SUPERFICIAL
  SPREADING

NODULAR



LENTIGO MALIGNA
BOB MARLEY IS A JAMAICAN HERO
 BOB MARLEY WAS A RASTAFARIAN
WHAT’S A
 “RASTAFARI”?            RAS (PRINCE) TAFARI
                         MAKONNAN
                         WAS CROWNED
                         EMPEROR OF
                         ETHIOPIA IN 1930.
                         HE THEN TOOK THE
                         NAME HAILE SELASSIE I
                         (THE NAME MEANS THE
                         ‘POWER OF THE
                         TRINITY’). HE CLAIMED
                         DESCENT FROM SHEBA
                         AND SOLOMON.


                HE WAS
THE STORY OF MARCUS GARVEY
1887-1940: FOUNDER
OF THE UNIVERSAL
NEGRO IMPROVEMENT
ASSOCIATION IN 1914

 “LOOK TO AFRICA FOR
 THE CROWNING OF A
 BLACK KING; HE SHALL
 BE THE REDEEMER.”
  MARCUS GARVEY: EARLY ‘BLACK
       POWER’ ADVOCATE
CHAMPION OF A “BACK TO AFRICA”
 MOVEMENT, WITH ETHIOPIA AS THE
 PROMISED LAND AND HAILE SELASSIE AS
 MESSIAH.
             RASTAFARIANS
DREADLOCKS




GANJA (MARIJUANA)
             RASTAFARIANS
“BLACK MAN’S BIBLE”-HOLY
  PIBY- AND ETHIOPIAN
  KEBRA NEGASI

PACIFISTS
MALE DOMINATED
ACEPHALOUS
REASONINGS AND
  “BINGHI” (OPPOSITION
TO OPPRESSION)
VEGETARIANS (I-TAL).
           RASTAFARIANS
THREE KEY CONCEPTS

   1.BABYLON
   2.I AND I
   3.JAH (GOD)
     AND THE LEGACY OF REGGAE
               MUSIC




THERE ARE PROBABLY NO MORE THAN 1 MILLION RASTAFARIANS WORLD-WIDE,
BUT MANY, MANY MORE- IN MULTIPLE DIVERSE COUNTRIES- LOVE REGGAE.
MAGICAL    MEDICAL
  HISTORY TOUR

   WHO IS THE PATIENT?
  WHAT IS THE DIAGNOSIS?
MORE AND BETTER TO FOLLOW!
  CHIEF COMPLAINT

 AN 83 YEAR OLD PHYSICIAN TOLD
 HIS DOCTOR "IT IS NOTHING BUT
TORTURE AND MAKES NO SENSE ANY
             MORE."
 HISTORY OF PRESENT ILLNESS
HE HAD BEGUN EXPERIENCING CHEST PAINS
  AND SHORTNESS OF BREATH IN HIS LATE
  THIRTIES.
AT AGE 67, HE DEVELOPED A PAINFUL LUMP ON
  HIS SOFT PALATE.
HE SUBSEQUENTLY UNDERWENT, DURING THE
  NEXT 16 YEARS, OVER THIRTY SURGERIES
  PLUS RADIATION THERAPY FOR THE LESION IN
  HIS MOUTH, WITH CONSIDERABLE PAIN,
  MUTILATION, DIFFICULTY SPEAKING AND
  EATING, AND PROGRESSIVE NECROSIS OF
  BOTH BONE AND SOFT TISSUE.
 HISTORY OF PRESENT ILLNESS
HE REQUIRED A PROSTHESIS (WHICH HE
 CALLED 'THE MONSTER') TO SEPARATE A
 NOW COMMON ORAL-NASAL CAVITY ,
 AND WOULD OCCASIONALLY HAVE TO
 USE A CLOTHES PIN TO OPEN HIS
 MOUTH TO EAT.
NONETHELESS, DURING THIS ILLNESS HE
 WROTE OVER TWENTY BOOKS AND
 ARTICLES.
 HISTORY OF PRESENT ILLNESS
DURING THIS ENTIRE PERIOD, WITH RARE
 EXCEPTIONS AND AGAINST MEDICAL
 ADVICE, HE SMOKED UP TO 20 CIGARS A
 DAY.
    PHYSICAL EXAMINATION
DESCRIBED AT THE END OF HIS LIFE AS
 CACHEXIC, WITH PROFOUND ORO-
 FACIAL MUTILATION, EXHAUSTED AND
 IN PAIN, BUT OF CLEAR MIND.
HIS LESION SMELLED SO BAD THAT EVEN
 HIS BELOVED DOG WOULD NOT COME
 NEAR HIM.
   COURSE OF FINAL ILLNESS
HE SAID TO HIS DOCTOR: "MY DEAR
 SCHUR, YOU CERTAINLY REMEMBER OUR
 FIRST TALK. YOU PROMISED THEN NOT
 TO FORSAKE ME…."
 HIS DOCTOR HAD NOT FORGOTTEN.
         THE PATIENT DIED
         IN COMA EARLY THE
           NEXT MORNING.
 SOME CLUES ABOUT OUR PATIENT
HE WENT TO MEDICAL                     JOSEPH BABINSKI
  SCHOOL IN VIENNA
  AND BECAME A
  NEUROLOGIST.
HE STUDIED IN
  FRANCE, ALSO, WITH
  THIS FAMOUS
  DOCTOR…..
JEAN-MARTIN
  CHARCOT

ARTIST:ANDRE BROUILLET-1887   GILLES de la TOURETTE
         HE DID RESEARCH
HE STUDIED NEURONS
  IN FISH, AND
  DISCOVERED THAT
  MALE EELS HAD
  TESTES.

HE ALSO STUDIED A
  LOCAL ANESTHETIC-
      COCAINE
  HE WAS IN PRACTICE, AND
TREATED NERVOUS DISORDERS
A FAMOUS PERSON HE DISCUSSED
       IN HIS WRITINGS
 HE LEFT VIENNA FOR LONDON
 WHEN HE WAS 82 YEARS OLD
THEN HIS COUNTRYMEN BURNED HIS BOOKS
       A VERY SOUND CLUE
THIS IS HIS VOICE, SPEAKING IN ENGLISH-
 BUT NOT VERY CLEARLY, BECAUSE OF
             HIS DISEASE
WHO WAS THE PATIENT?
                          FACE WIZARD




1856               1939




       SIGMUND FREUD
       WHAT DID HE SAY?
“I STARTED MY PROFESSIONAL ACTIVITY
  AS A NEUROLOGIST TRYING TO BRING
  RELIEF TO MY NEUROTIC PATIENTS.
  UNDER THE INFLUENCE OF AN OLDER
  FRIEND AND BY MY OWN EFFORTS I
  DISCOVERED SOME IMPORTANT NEW
  FACTS ABOUT THE UNCONSCIOUS IN
  PSYCHIC LIFE, THE ROLE OF
  INSTINCTUAL URGES AND SO ON.”
            SIGMUND FREUD
      FATHER OF PSYCHOANALYSIS

                        NEUROSIS
                        PENIS ENVY
                        TRANSFERENCE
ID                      CATHARSIS
EGO                     ELECTRA COMPLEX
SUPER-EGO               REPRESSION
LIBIDO                  PROJECTION
EROS                    RATIONALIZATION
PLEASURE PRINCIPLE      FREE ASSOCIATION
THE OEDIPUS COMPLEX


                THIS DID NOT TURN
                OUT WELL- EITHER
                FOR OEDIPUS OR
                FREUD. PEOPLE
                WERE DISGUSTED
                BY THE IDEA OF A
                BOY LUSTING
                AFTER HIS MOTHER…
           FREUD ESCAPES !
IN 1938, UPON THE VERY GOOD
  ADVICE OF FRIENDS, FREUD-
  A JEW – LEFT AUSTRIA AND
  WENT TO LONDON.

THE NAZIS PUBLICALLY BURNED
  HIS BOOKS (AND THOSE OF
  MANY OTHERS).

NAZIS SHORTLY LATER MOVED
  ON TO BURNING JEWS, AND
  MANY OTHERS.
WHAT WAS THE DIAGNOSIS?
                                        DX WIZARD




     CANCER OF THE MOUTH

    BUT THE CANCER WAS NOT THE DIRECT
          CAUSE OF FREUD’S DEATH
  THEN WHAT DID CAUSE HIS
         DEATH?
HE AND HIS DOCTOR HAD AN AGREEMENT




   HIS DOCTOR GAVE HIM 20MG OF
            MORPHINE.
 FREUD SLEPT AND NEVER WOKE AGAIN
 FREUD MADE MUCH OF THE
INTERPRETATION OF DREAMS
   SOME HAVE ASKED IF LIFE IS A
            DREAM.
“…YOU ARE NOT WRONG WHO DEEM
THAT MY DAYS HAVE BEEN A DREAM;
YET IF HOPE HAS FLOWN AWAY
IN A NIGHT, OR IN A DAY,
IN A VISION, OR IN NONE,
IS IT THEREFORE THE LESS GONE?
ALL THAT WE SEE OR SEEM
IS BUT A DREAM WITHIN A DREAM…”
                         EDGAR ALLAN POE
  MAYBE POE READ THIS MAN'S
   PHILOSOPHIC DISCOURSE
"COGITO                     ERGO SUM"



    1596                    1650




           RENÉ DESCARTES
ARE WE ‘DREAMING’ EVERYTHING?

ALL SURROUNDING PHENOMENA WE BELIEVE ARE ‘REAL’, EVEN
OUR OWN BODIES, COULD BE JUST THE PRODUCTS OF THE
          MIND, CREATING A WORLD



                                        THE ONLY THING WE
                                        CAN BE SURE OF IS
                                        THIS:IF I DOUBT, THEN
                                        THERE MOST BE A
                                        THINKING THING THAT
                                              DOUBTS
                                         I THINK, THEREFORE
                                              I AM
 DESCARTES DIVIDED ‘REALITY’
RES COGNITAS
  (CONSCIOUSNESS,
  MIND)




RES EXTENSA (MATTER,
  EXTENSION)
      COGNITAS AND EXTENSA
DESCARTES ARTICULATED THE MIND-BODY
  INTERACTION…AND KNEW THAT BOTH
  PERCEPTION AND REASON CAN DECEIVE US.

HE BELIEVED THEY CONNECTED AND
  INFLUENCED EACH OTHER VIA SENSES AND
  THE NERVOUS SYSTEM.



FREUD SAID MUCH THE SAME IN ANOTHER CONTEXT:HYSTERIA, DREAM
               SYMBOLISM, NEUROSES
    DESCARTES ON ANIMALS
HE BELIEVED THEY
  WERE AUTOMATONS,
  LACKING EITHER
  SENSATION OR SELF
  AWARENESS.



          WRONG!
    PATIENTS OFTEN TELL US..
“MY PET COMFORTS ME.”

“MY DOG ALWAYS KNOWS
  HOW I FEEL.”



“MY CAT UNDERSTANDS ME
  BETTER THAN MY
  SPOUSE DOES”
AN EXPERIMENT WITH ANIMALS
THE DOG VS CHIMP STUDY:

                          BRIAN HARE
                          OF HARVARD:
                          SCIENCE,2002




                                 DOGS COMPREHEND
                                 HUMAN COMMUNICATION
                                 MUCH BETTER THAN OUR
                                 NEAREST NON-HUMAN
                                 RELATIVE.
    DOGS ARE HIGHLY SELECTED
            EMPATHS
MAYBE THAT’S WHY FREUD CHOSE FOR EUTHANASIA




                                       AND MANY
                                       MODERN
                                       PSYCHIATRISTS
                                       HAVE GIVEN
                                       UP ON HIM
         HE WAS IN PAIN, HE COULDN’T   AS WELL
            WORK ANYMORE, AND
        EVEN HIS DOG GAVE UP ON HIM…
 AN UNKIND SONG ABOUT FREUD*
WELL IT STARTED IN VIENNA NOT SO MANY YEARS AGO
WHEN NOT ENOUGH FOLKS WERE GETTING SICK
A STARVING YOUNG PHYSICIAN TRIED TO BETTER HIS
  CONDITION
BY DISCOVERING WHAT MADE HIS PATIENTS TICK

HE FORGOT ABOUT SCLEROSIS AND INVENTED THE NEUROSIS
AND THE HUNDRED WAYS THAT SEX COULD BE ENJOYED
HE ADOPTED AS HIS CREDO “DOWN REPRESSION, UP LIBIDO”
AND THAT’S WHAT STARTED DR. SIGMUND FREUD

 OH DR. FREUD, OH DR. FREUD
HOW I WISH YOU HAD BEEN DIFFERENTLY EMPLOYED
BUT THE SET OF CIRCUMSTANCES STILL ENHANCES THE
  FINANCES
OF THE FOLLOWERS OF DR. SIGMUND FREUD

        *BASED ON MY MEMORY OF A POEM BY TOM LEHRER SET TO
        THE TUNE “WHEN THE SAINTS COME MARCHING IN.”
MAGICAL    MEDICAL
  HISTORY TOUR

   WHO IS THE PATIENT?
  WHAT IS THE DIAGNOSIS?
MORE AND BETTER TO FOLLOW!
 CHIEF COMPLAINT

A 64 YEAR OLD MUSICIAN HAD
     FAILING EYESIGHT.
  HISTORY OF PRESENT ILLNESS
HE HAD TROUBLE WITH HIS EYES OVER SEVERAL
  YEARS WHICH HE ATTRIBUTED TO READING
  BY CANDLELIGHT.
HE BEGAN THEN TO RAPIDLY LOSE VISION, AND
  SUBMITTED TO “COUCHING”* BY AN
  ENGLISHMAN NAMED “CHEVALIER” JOHN
  TAYLOR.
    * ‘COUCHING’ WAS A PROCEDURE IN WHICH
  A CATARACTOUS LENS WAS PUSHED
  BACKWARDS INTO THE VITREOUS.
                                 OUCH!
 HISTORY OF PRESENT ILLNESS
TWO OPERATIONS
 WERE PERFORMED,
 MEDICATIONS TO
 THE EYES WERE           HE WENT
 GIVEN, AND ALL OF       BLIND…

 THESE MADE HIM
 WORSE.



                     TAYLOR WAS A QUACK
PAST, SOCIAL, FAMILY HISTORY
HE WAS ONE OF EIGHT
  SONS IN A GERMAN
  MUSICAL FAMILY, AND
  BECAME A MUSICIAN
  AND COMPOSER.
HE HAD OVER TWENTY
  CHILDREN (OF TWO
  WIVES). FOUR OF HIS
  SONS WERE ALSO
  FAMOUS MUSICIANS.
     PHYSICAL EXAMINATION
HIS EYES MAY HAVE
  LOOKED LIKE THIS
     PHYSICAL EXAMINATION
HIS VISION MAY HAVE BEEN LIKE THIS….
                       OR THIS
      COURSE OF ILLNESS
WITHIN 6 MONTHS AFTER HIS
 DISASTEROUS TREATMENTS, HE DIED OF
 A STROKE.


THEN EVERYBODY FORGOT ABOUT HIM
      WHO WAS THE PATIENT?
          SOME CLUES
HE WAS A RENOWNED
  ORGANIST




HE NEVER LEFT GERMANY
        A MUSICAL CLUE
  HE WROTE THIS FOR THE ORGAN




IT IS CALLED “IN DULCE
JUBILO”
A SECOND MUSICAL CLUE
 HE ALSO WROTE THIS
WHO WAS THE PATIENT?
                            FACE WIZARD




1685                 1750




   JOHANN SEBASTIAN BACH
WHAT WAS THE DIAGNOSIS?
                                       DX WIZARD



UNCERTAIN, BUT POSSIBILITIES INCLUDE

            DIABETES
 CATARACTS                GLAUCOMA
   HISTORY HELPS.
WHAT DOES IT LOOK LIKE?
BACH WAS BURIED IN OBLIVION IN
      LEIPZIG, GERMANY
 THEN THIS MAN CAME ALONG

                            HE ‘REDISCOVERED’ BACH
                            AND PRESENTED HIS WORK
                            TO THE WORLD IN 1829.
                            THE WORLD LOVED IT!




FELIX MENDELSSOHN(1809-1847)
                     P.S.
MENDELSSOHN WAS
ALSO A PRETTY GOOD
COMPOSER…YOU ALL
KNOW HIS WORK.


       HE WROTE MANY WONDERFUL
       THINGS, BUT IS MAINLY
       REMEMBERED FOR HIS
       WEDDING MARCH.
   MENDELSSOHN’S SAD STORY
HE WAS A CHILD PRODIGY,
  WRITING MUSIC FOR
  OPERA, SYMPHONIES,
  CHORALS, VIOLIN,
  ORCHESTRA, CHAMBER,
  AND ‘REDISCOVERING’
  BACH.
HIS BELOVED AND EQUALLY
  GIFTED OLDER SISTER,
  FANNY, DIED OF
  CEREBRAL HEMORRHAGE
  AT AGE 43.
WITHIN 6 MONTHS,
  MENDELSSOHN DIED OF
  THE SAME AFFLICTION,
  AGE 38.
       BUT THERE’S MORE!
AND BETTER!




BACH IS RELATED TO OUR HOUSE OF
 MEDICINE IN A VERY SPECIAL WAY.
REMEMBER THIS CLUE?




 BACH’S ‘JESU, HEART OF MAN’S DESIRING’
ANOTHER FAMOUS PERSON WAS A
        J.S. BACH FAN
HE WROTE, AMONG
  OTHER THINGS, A
  WELL KNOWN BOOK
  ABOUT JESUS.
        ALBERT SCHWEITZER
            1875-1965
BORN IN GERMANY, HE
  STUDIED MUSIC AND
  THEOLOGY, THEN
  WENT TO MEDICAL
  SCHOOL AT AGE 30
  IN ORDER TO
  BECOME A MEDICAL
  MISSIONARY IN
  AFRICA.
  IN 1913, HE ESTABLISHED HIS
HOSPITAL AT LAMBARENE IN WHAT
        IS NOW GABON.
HE SUPPORTED HIS WORK, IN
  PART, BY GIVING ORGAN
        CONCERTS…
     ..OF BACH’S MUSIC!
ALBERT SCHWEITZER M.D.,PhD.
HE WON THE NOBEL
  PEACE PRIZE FOR
  THE YEAR 1952.
         TWO GOOD MEN WHO HAVE
        ENRICHED THE SPIRIT OF THE
                 WORLD




"SHEEP MAY SAFELY
GRAZE"
AND THAT’S ALL


THANKS FOR LISTENING

								
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