Special Subjects

Before elective surgical procedures, a thorough preoperative medical evaluation by nonsurgical consultants (eg, internists, cardiologists, pulmonologists) may be necessary to help assess surgical risk. Such consultants may also help manage preexisting disease (eg, diabetes) and help prevent and treat perioperative and postoperative complications (eg, cardiac, pulmonary, infectious). Psychiatric consultation is occasionally needed to assess capacity or help deal with underlying psychiatric problems that can interfere with recovery.

Chronic fatigue syndrome (CFS) is a syndrome of life-altering fatigue lasting > 6 months that is unexplained and is accompanied by a number of associated symptoms. Management includes validating the patient's disability, treating specific symptoms, and in some patients cognitive-behavioral therapy and a graded exercise program.

Clinicians must integrate a huge variety of clinical data while facing conflicting pressures to decrease diagnostic uncertainty, risks to patients, and costs. Deciding what information to gather, which tests to order, how to interpret and integrate this information to draw diagnostic conclusions, and which treatments to give is known as clinical decision making.

Integrative medicine and health (IMH) and complementary and alternative medicine (CAM) include healing approaches and therapies that historically have not been included in conventional, mainstream Western medicine.

Dietary supplements are the most commonly used of all integrative, complementary, and alternative therapies, primarily because they are widely available, relatively inexpensive, and can be bought without consulting a health care practitioner.

Dying patients can have needs that differ from those of other patients. So that their needs can be met, dying patients must first be identified. Before death, patients tend to follow 1 of 3 general trajectories of functional decline:

Exercise stimulates tissue change and adaptation (eg, increase in muscle mass and strength, cardiovascular endurance), whereas rest and recovery allow such change and adaptation to occur (1). Recovery from exercise is as important as the exercise stimulus. Regular physical activity reduces the likelihood of medical illness, decreases the incidence of the major causes of death, and improves the overall health and quality of life for patients with most medical conditions.

Health care in the US is technologically advanced but expensive, costing about $3.6 trillion in 2018, which was 16.9% of gross domestic product (GDP) (1). This percentage is significantly higher than in any other nation. According to the Organization for Economic Cooperation and Development (OECD), in 2018 the next highest spending countries were Switzerland (12.2% of GDP) and France, Germany, Sweden, and Japan (each about 11%), while the average of the 35 OECD countries (OECD35) was 8.8% (2).

A gene, the basic unit of heredity, is a segment of DNA containing all the information necessary to synthesize a polypeptide (protein). Protein synthesis, folding, and tertiary and quaternary structure ultimately determine much of the body’s structure and function.

The amount of information that must be learned in medical school is so much larger than in college that new study techniques may be required.

Idiopathic environmental intolerance is characterized by recurrent, nonspecific symptoms attributed to low-level exposure to chemically unrelated substances commonly occurring in the environment or sometimes to hypersensitivity to electromagnetic fields. Symptoms are numerous, often involving multiple organ systems, but physical findings are unremarkable. Diagnosis is by exclusion. Treatment is psychologic support and avoidance of perceived triggers, although triggers rarely can be defined.

A limb prosthesis is an artificial limb that replaces a missing body part.

Appropriate planning reduces the risks associated with travel, including air travel. Prior to travel, patients and their medical providers should review planned itineraries and relevant medical histories, required vaccinations, prophylactic measures against infections such as malaria and traveler's diarrhea, and advice about personal protection measures, including those related to noninfectious threats. For older travelers, the most common causes of death are heart attack and stroke; for other travelers, the most common cause of death is road traffic crashes.

Historically, “incapacity” was considered primarily a clinical finding, and “incompetency” was considered a legal finding. That distinction, at least in terminology, is no longer firmly recognized; most state laws now use “incapacity” rather than “incompetency,” although the terms are frequently used interchangeably. The more useful distinction in terminology now is between clinical incapacity and legal incapacity to make a health care decision.

Fatigue occurs most often as part of a symptom complex, but even when it is the sole or main presenting symptom, fatigue is one of the most common symptoms.

Ionizing radiation (see also Radiation Exposure and Contamination) includes

Rehabilitation aims to facilitate recovery from loss of function. Loss may be due to fracture, amputation, stroke or another neurologic disorder, arthritis, cardiac impairment, or prolonged deconditioning (eg, after some disorders and surgical procedures). Rehabilitation may involve

Tobacco use is a major individual and public health problem. Dependence develops rapidly. Major consequences include premature death and morbidity caused by cardiovascular disease, lung and many other types of cancer, COPD, and other disorders. All patients who smoke should be offered smoking cessation interventions.

Body packing and body stuffing involve swallowing drug-filled packets or placing them in body cavities to evade detection by law enforcement. The risks and consequences vary depending on the amount and type of drug and the way it is packaged.