BROWSE SURGICAL BOOK

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The fourth edition of this essential textbook has been fully revised and updated to ensure it continues to meet the needs of all those learning the principles of. Browse's Introduction to the Symptoms & Signs of Surgical Disease 4th Edition. Pages · · MB Interchange 4th Edition Level 1 Student Book. The fourth edition of this essential textbook continues to meet the needs of all those learning the principles of surgical examination. Together.


Browse Surgical Book

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The fourth edition of this essential textbook continues to meet the needs of all those learning the principles of surgical examination. Together with Sir Norman. Browse's Introduction to the Symptoms and Signs of Surgical Disease book. Read 19 reviews from the world's largest community for readers. The fourth edit. Written for medical students and junior doctors, the fifth edition of this essential textbook has been fully revised and updated, including additional illustrations and.

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Browse ,. John Black. Kevin G. William E.

The fourth edition of this essential textbook continues to meet the needs of all those learning the principles of surgical examination. Together with Sir Norman Browse, the three additional authors bring their specialized knowledge and experience to complement the book's clear, didactic approach and broad insight into the general principles of surgery.

The fourth edition in The fourth edition of this essential textbook continues to meet the needs of all those learning the principles of surgical examination. The fourth edition includes revised content on muscles, tendons, bones, and joints and further updates in the breast chapter describe benign breast disease and the classification of cancer staging. This edition includes numerous illustrations, with additional photographs showing the more subtle surgical signs and demonstrating new approaches to surgical examination.

The authors also place a greater emphasis on the doctor-patient relationship and patient confidentiality. Get A Copy. Paperback , 4th Edition , pages. More Details Original Title. Other Editions Friend Reviews. To see what your friends thought of this book, please sign up. To ask other readers questions about Browse's Introduction to the Symptoms and Signs of Surgical Disease , please sign up. Majed Abdulqader I can download this book free by this amazing web.

Lists with This Book. Community Reviews. Showing Rating details. More filters. Sort order. Dec 26, Ahmad added it. Great book for medical students who intend to do surgery in future, awesome book Nov 16, Amirul Izwan rated it liked it. This book is not a fact book but it's more a practical point of view during round. It's easy to read and has a lots of picture. View 1 comment.

Jan 02, Sadiq marked it as to-read Shelves: Jun 04, P-the book nerd rated it it was amazing Shelves: Perfect book for clinical sessions of surgery.

Sep 06, Smit added it. Dec 23, Guuleed is currently reading it Shelves: Negative answers are just as important as positive answers.

The standard set of direct questions is described in detail below because they are so important. It is essential to know them by heart because it is very easy to forget to ask some of them.

When you have to go back to the patient to ask a forgotten question, you invariably find the answer to be very impor- tant. The only way to memorize this list is by taking as many histories as possible and writing them out in full.

All the answers to every question, whether they be positive or negative, must be recorded. The alimentary system Appetite Has the appetite increased, decreased, or remained unchanged?

If it has decreased, is this caused by a lack of desire to eat, or is it because of apprehension as eating always causes pain?

1st Edition

Diet What type of food does the patient eat? Are they vegetarian? When do they eat their meals? By how much? Over how long a time? Many patients never weigh themselves, but they usually notice if their clothes have got tighter or looser and friends may have told them of a change in physical appearance. Teeth and taste Can they chew their food?

Do they have their own teeth? Do they get odd tastes and sen- sations in their mouth? Are there any symptoms of water brash or acid brash? This is sudden filling of 2 Chap How to take the history 3 Revision panel 1.

History of present complaint HPC Include the answers to the direct questions concerning the system of the presenting complaint. Systematic direct questions a Alimentary system and abdomen AS Appetite. Indigestion pain. Abdominal pain. Abdominal distension. Bowel habit. Nature of stool. Rectal bleeding. Chest pain. Exercise tolerance. Paroxysmal nocturnal dyspnoea.

Ankle swelling. Limb pain. Walking distance. Colour changes in hands and feet. Frequency of micturition including nocturnal frequency. Poor stream. Painful micturition.

In men Problems with sexual intercourse and impotence. In women Date of menarche or menopause. Quantity and duration of menstruation. Vaginal discharge. Previous pregnancies and their complications. Urinary incontinence. Breast pain. Nipple discharge. Skin changes. Memory loss. Syncopal attacks. Loss of consciousness.

Muscle weakness. Sensory disturbances. Changes of smell, vision or hearing. Swelling joints. Limitation of joint movements. Disturbances of gait. Previous history PH Previous illnesses. Operations or accidents. Rheumatic fever. Bleeding tendencies. Hay fever. Tropical diseases. Drug history Insulin. Anti-depressants and the contraceptive pill.

Drug abuse. Immunizations BCG. Whooping cough. Family history FH Causes of death of close relatives. Familial illnesses in siblings and offspring. Social history SH Marital status. Sexual habits. Living accommodation. Exposure to industrial hazards. Travel abroad. Leisure activities. Habits Smoking. Number of cigarettes smoked per day. Units of alcohol drunk per week. History taking and clinical examination the mouth with watery or acid-tasting fluid — saliva and gastric acid respectively.

Swallowing If they complain of difficulty in swal- lowing dysphagia , ask about the type of food that causes difficulty,the level at which the food sticks,and the duration and progression of these symptoms. Is swallowing painful? Regurgitation This is the effortless return of food into the mouth.

It is quite different from vomiting, which is associated with a powerful involuntary con- traction of the abdominal wall. Do they regurgitate? What comes up? If food, is it digested or recognizable and undigested? How often does it occur and does anything,such as stooping or straining,precipitate it? Flatulence Does the patient belch frequently? Does this relate to any other symptoms?

Heartburn Patients may not realize that this symptom comes from the alimentary tract and they may have to be asked about it directly. It is a burning sensation behind the sternum caused by the reflux of acid into the oesophagus. How often does it occur and what makes it happen, e. Vomiting How often do they vomit? Is the vomiting preceded by nausea? What is the nature and volume of the vomitus? Is it recognizable food from previ- ous meals, digested food, clear acidic fluid or bile- stained fluid?

Is the vomiting preceded by another symptom such as indigestion pain, headache or gid- diness? Does it follow eating? Haematemesis Always ask if they have ever vomited blood because it is such an important symptom.

Some patients have difficulty in differentiating between vomited or regurgitated blood and coughed-up blood haemoptysis.

The latter is usually pale pink and frothy. When patients have had a haematemesis, always ask if they have had a recent nose bleed.

They may be vomiting up swallowed blood. Indigestion or abdominal pain Some people call all abdominal pains indigestion; the difference between a discomfort after eating and a pain after eating may be very small. Concentrate on the features of the pain, its site, time of onset, severity, nature, progres- sion, duration, radiation, course, precipitating, exac- erbating and relieving factors see pages 7— Abdominal distension Have they noticed any abdom- inal distension?

What brought this to their atten- tion? When did it begin and how has it progressed? Is it constant or variable? What factors are associ- ated with any variations?

Is it painful?

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Does it affect their breathing? Is it relieved by belching, vomiting or defaecation? Defaecation How often does the patient defaecate? What are the physical characteristics of the stool? They are lay words and mean different things to dif- ferent people. These words should not be written in the notes without also recording the frequency of bowel action and the consistence of the faeces.

Rectal bleeding Has the patient ever passed any blood in the stool? Was it bright or dark? How much? Was it mixed in with or on the surface of the stool, or did it only appear after the stool had been passed? Flatus, mucus, slime Is the patient passing more gas than usual? Has the patient ever passed mucus or pus? Is defaecation painful? When does the pain begin — before, during, after, or at times unrelated to defaecation?

Prolapse and incontinence Does anything come out of the anus on straining? Does it return spontane- ously or have to be pushed back? Is the patient con- tinent of faeces and flatus?

Browse's introduction to the symptoms & signs of surgical disease

Have they had any injuries or anal operations in the past? Tenesmus Do they experience any urgent, painful but unproductive desire to pass stool? This is called tenesmus.

How long did it last? Were there any other accompanying symp- toms such as abdominal pain or loss of appetite? Did the skin itch? The respiratory system Cough How often does the patient cough? Does the coughing come in bouts? Does anything, such as a 4 Chap How to take the history change of posture, precipitate or relieve the cough- ing?

Is it a dry or a productive cough? Sputum What is the quantity teaspoon, dessert- spoon,etc. Some patients only produce sputum in the morning or when they are in a particular position.

Haemoptysis Has the patient ever coughed up blood? Was it frothy and pink? Were there red streaks in the mucus, or clots of blood? What quantity was pro- duced? How often does the haemoptysis occur? Dyspnoea Does the patient wheeze?

Does he get breathless? How many stairs can he climb? How far can he walk on a level surface before the dyspnoea interferes with the exercise?

Can he walk and talk at the same time? Is the dyspnoea present at rest? Is it present when sitting or made worse by lying down? Dyspnoea on lying flat is called orthop- noea.

How many pillows does the patient need at night? Does the breathlessness wake them up at night — paroxysmal nocturnal dyspnoea — or get worse if they slip off their pillows? There are classi- fications that grade dyspnoea numerically, but it is better to describe the causative conditions rather than write down a number.

Is the dyspnoea induced or exacerbated by exter- nal factors such as allergy to animals, pollen or dust? Does the difficulty with breathing occur with both phases of respiration or on expiration? Pain in the chest Ascertain the site, severity and nature of the pain. Chest pains can be continuous, pleuritic made worse by inspiration , constricting or stabbing. Orthopnoea and paroxysmal nocturnal dyspnoea Orthopnoea and paroxysmal nocturnal dyspnoea are the forms of dyspnoea especially associated with heart disease.

Pain Cardiac pain begins in the mid-line and is usually retrosternal but may be epigastric. It is often described as constricting or band-like. It is usually brought on by exercise or excitement. The patient should be asked if the pain radiates to the neck or to the left arm and whether it is relieved by rest.

Palpitations These are episodes of tachycardia which the patient notices as a sudden fluttering or thump- ing of the heart in the chest. Ankle swelling Do the ankles or legs swell? When do they swell? Dizziness, headache and blurred vision These are some of the symptoms associated with hyperten- sion and postural hypotension. Peripheral vascular symptoms Does the patient get pain in the leg muscles on exer- cise intermittent claudication?

Which muscles are involved?

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How far can the patient walk before the pain begins? Is the pain so bad that he has to stop walking? How long does the pain take to wear off? Can the same distance be walked again?

Is there any pain in the limb at rest? Which part of the limb is painful? Does the pain interfere with sleep? What positions relieve the pain? What analgesic drugs give relief? Are the extremities of the limbs cold? Are there colour changes in the skin, particularly in response to a cold environment?

Does the patient experience any paraesthesiae in the limb, such as tingling or numbness? The urogenital system Urinary tract symptoms Pain Has there been any pain in the loin, groin or suprapubic region? What is its nature and severity? Does it radiate to the groin or scrotum? Oedema Do any parts of the body other than the ankles swell? Thirst Is the patient thirsty? Do they drink excessive volumes of water? Micturition How often does the patient pass urine?

How much urine is passed? Is the volume and frequency excessive polyuria? Is micturition painful? What is the nature and site of the pain? Is there any difficulty with micturition, such as a need to strain or to wait? Is the stream good? Can it be stopped at will? Is there any dribbling at the end of micturition? Does 5 Chap History taking and clinical examination the bladder feel empty at the end of micturition or do they have to pass urine a second time?

Urine Has the patient ever passed blood in the urine? When and how often? Have they ever passed gas bubbles with the urine pneumaturia? Symptoms of uraemia These include headache, drowsiness, visual disturbance, fits and vomiting.

Genital tract symptoms MALE Scrotum, penis and urethra Has the patient any pain in the penis or urethra during micturition or intercourse? Is there any difficulty with retraction of the prepuce or any urethral discharge? Has the patient noticed any swelling of the scrotum? Can he achieve an erection and ejaculation? When did it end menopause?

What is the duration and quantity of the menses? Is menstrua- tion associated with pain dysmenorrhoea? What is the nature and severity of the pain? Is there any abdominal pain mid-way between the periods mit- telschmerz? Has the patient had any vaginal dis- charge? What is its character and amount? Has she noticed any prolapse of the vaginal wall or cervix or any urinary incontinence, especially when straining or coughing stress incontinence?

Dyspareunia Is intercourse painful? Breasts Do the breasts change during the men- strual cycle? Are they ever painful or tender? Has the patient noticed any swellings or lumps in the breasts? Did she breast-feed her children? Has there been any nipple discharge or bleeding?

Has she noticed any skin changes over the breasts?

Secondary sex characteristics When did these appear? The nervous system Mental state Is the patient placid or nervous? Has the patient noticed any changes in their behaviour or reactions to others? Patients will often not appre- ciate such changes themselves and these questions may have to be asked of close relatives.

Does the patient get depressed and withdrawn, or are they excitable and extroverted? Brain and cranial nerves Does the patient ever become unconscious or have fits? What happens during a fit? It is often necessary to ask a relative or a bystander to describe the fit. Did the patient lie still or jerk about, bite their tongue, pass urine? Was the patient sleepy after the fit? Was there any warning an aura that the fit was about to develop? Has there been any subsequent change in the senses of smell, vision and hearing?

Is there a history of headache? Where is it experi- enced? When does it occur? Are the headaches asso- ciated with any visual symptoms?

Has the face ever become weak or paralysed? Have any of the limbs been paralysed or had pins and needles? Has there ever been any buzzing in the ears, dizziness or loss of speech? Can the patient speak clearly and use words properly? Peripheral nerves Are any limbs or part of a limb weak or paralysed?

Is there ever any loss of cutaneous sensation anaesthesia? Musculoskeletal system Ask if the patient suffers from pain, swelling or lim- itation of the movement of any joint. What precipi- tates or relieves these symptoms?

What time of day do they occur? Are any limbs or groups of muscles weak or painful? Can he walk normally? Has he any congenital musculoskeletal deformities?

Previous history of other illnesses, accidents or operations Record the history of those conditions which are not directly related to the present complaint. Ask specif- ically about tuberculosis, diabetes, rheumatic fever, allergies, asthma, tropical diseases, bleeding tenden- cies, diphtheria, gonorrhoea, syphilis, and the likeli- hood of intimate contact with carriers of the human immunodeficiency virus HIV.

Drug history Ask if the patient is taking any drugs. Specifically, enquire about steroids, anti-depressants, insulin, 6 Chap History of pain diuretics, anti-hypertensives, hormone replacement therapy and the contraceptive pill.

Patients usually remember about drugs prescribed by a doctor but often forget about self-prescribed drugs they have bought at a pharmacy. Is the patient sensitive to any drugs or any topical applications such as adhesive plaster? If they are, write it in large letters on the front of the notes.

Immunizations Most children are immunized against diphtheria, tetanus, whooping cough, measles, mumps, rubella and poliomyelitis. Ask about these, and smallpox, typhoid and tuberculosis vaccination. Draw a family tree if there is obvious familial dis- order e. Did she take any drugs during pregnancy? Were there any difficulties during delivery?

What was the rate of physical and mental development in early life? Social history Record the marital status and the type and place of dwelling. Has the patient travelled abroad? List the countries visited and the dates of the visits if these appear to be relevant. Habits Does the patient smoke? If so what — cigarettes, cigar or pipe? Record the frequency, quantity and duration of their smoking habit. Does the patient drink alco- hol? Record the type and quantity consumed and the duration of the habit.

Does the patient have any unusual eating habits? It is an unpleasant sensation of varying intensity. Be careful in your use of the word tenderness. It is possible for a patient to be lying still without pain and yet have an area of tenderness. The patient feels pain — the doctor elicits tenderness.

Browse's Introduction to the Symptoms and Signs of Surgical Disease

But although patients usually complain of pain, they may also have observed and complain of tenderness if they happen to have pressed their fingers on a painful area or discovered a tender spot by accident. Thus tenderness can be both a symp- tom and a physical sign.

The history of a pain frequently betrays the diag- nosis, so you must question the patient closely about each of the following features, some of which are depicted graphically in Figure 1. Site Many factors may indicate the source of the pain but the most valuable indicator is its site. Although patients do not describe the site of their pain in anatomical terms, they can always point to the site of max- imum intensity, which you can convert into an exact description. When the pain is indistinct in nature and spread diffusely over a large area, you must describe the area in which the pain is felt and the point indi- cated by the patient of maximum discomfort.

It is also worthwhile asking about the depth of the pain. Patients can often tell you whether the pain is near to the skin or deep inside.

Time and mode of onset It may be possible to pinpoint the onset of the pain to the minute, but if this cannot be done, the part of 7 Chap Progression a Steady b Gradual decline c Gradual worsening d Fluctuating Duration Severity Onset a Sudden onset at maximum severity b Sudden onset and subsequent decline c Gradual onset End a Sudden cessation b Gradual end c Crescendo and then sudden end a b c d a a b b c c History taking and clinical examination the day or night when the pain began should be recorded.

You should record the calendar dates on which events occurred, but it is also very useful to add in brackets the time interval between each event and the current examination, because it is these intervals, not the actual dates, which are more rele- vant to the problems of diagnosis.

Whenever you write a note about a patient, whether it be a short progress note or a full history, make certain that you start your notes by writing down the date. Ask if the pain began insidiously or suddenly. Severity Individuals react differently to pain. What is a severe pain to one person might be described as a dull ache by another. Consequently you must be wary of the adjectives used by a patient to describe the severity of their pain. Did it stop the patient going to work? Did it make the patient go to bed?

Did they try proprietary analgesics? Did they have to call their doctor? Did it wake the patient up at night, or stop them going to sleep? Was the pain better lying still or did it make the patient roll around? The answers to these questions provide a better indi- cation of the severity of a pain than words such as mild, severe, agonizing or terrible.

Your assessment 8 FIG 1. Always record dates and calculate time intervals. History of pain of the way the patient responds to their pain, formed while you are taking the history, may profoundly affect your treatment. Nature or character of the pain Patients find it very difficult to describe the nature of their pain, but some of the adjectives which are commonly used, such as aching, stabbing, burn- ing, throbbing, constricting, distending, gripping or colic, have a similar meaning to the majority of people.

We have all experienced a throbbing sensa- tion at some time in our life, so this description is also usually accurate.

A stabbing pain is sudden, severe, sharp, and short-lived. The adjective constricting suggests a pain that encircles the relevant part chest, abdomen, head or limb and compresses it from all directions. A pain that feels like an iron band tightening around the chest is typical of angina pectoris and almost diag- nostic, but when patients speak of a tightness in their chest or limb do not immediately assume that they have a constricting pain. They may be describ- ing a tightness caused by distension, which may occur in any structure that has an encircling and restricting wall,such as the bowel,bladder,an encap- sulated tumour or a fascial compartment.

Tension in the containing wall may cause a pain which the patient may describe as distension, tightness or a bursting feeling. A colicky pain has two features. First, it comes and goes in a sinusoidal way. Second, it feels like a migrating constriction in the wall of a hollow tube which is attempting to force the contents of the tube forwards.

It is not a word which many patients use and it is dangerous to ask them if their pain is col- icky without giving an example. This is not difficult, because most of us have experienced colic during an episode of diarrhoea,and many women have suffered the colicky pains of labour. A recurring, intermittent pain is not necessarily a colic; it must also have a gripping nature.

This may vary in severity from a mild discomfort or ache, to an agonizing pain that makes them think they are about to die.

Browse's Introduction to the Symptoms and Signs of Surgical Disease (4th edn)

When a patient cannot describe the nature of their pain, do not press the point. You will only make them try to fit their pain to your suggestions and ultimately this may be misleading. Duration Record the duration of the pain. Severity Assess severity by its effect on the patient. Radiation Record the time and direction of any radiation of the pain; remember to ask if the nature of the pain changed at the time it moved.

Referral Was the pain experienced anywhere else? Progression Describe the progression of the pain. Did it change or alter? The end of the pain Describe how the pain ended. Was the end spontaneous or brought about by some action by the patient or doctor? History taking and clinical examination Progression of the pain Once it has started, a pain may progress in a variety of ways. The intensity of the pain at the peaks and troughs of the fluctuations, and the rate of development and regression of each peak, may vary.

The pain may go completely between each exacerbation. The time between the peaks of an abdominal colic may indicate the likely site of a bowel obstruction e.

It is essential to find out how the pain has progressed and ascertain the timing of any fluctuations before its nature can be determined; for example, colic has two features — its gripping nature and its intermittent progression. The end of the pain A pain may end spontaneously, or as a result of some action by the patient or doctor. The end of a pain is either sudden or gradual. The way a pain ends may give a clue to the diagnosis, or indicate the develop- ment of a new problem. Patients always think that the disappearance of their pain means that they are getting better.

They are usually right, but sometimes their condition may have got worse. Duration of the pain The duration of a pain will be apparent from the time of its onset and end, but nevertheless it is worth- while stating the duration of the pain in your notes.

The length of any periods of exacerbation or remis- sion should also be recorded. Factors which relieve the pain Patients will know if there is anything, such as posi- tion, movement, a hot-water bottle, aspirins, food, antacids, etc. The natural response to a pain is to search for a way to relieve it. Sometimes patients try the most bizarre remedies and many convince themselves that some minor change in habit or a personal remedy has been helpful, so accept their replies to this question with caution.

Factors which exacerbate the pain Anything that makes the pain worse is also likely to be known to the patient. The type of stimulus that exacerbates a pain will depend on the organ from which it emanates and its cause. For example, alimentary tract pains may be made worse by eating particular types of food; mus- culoskeletal pains are affected by joint movements, muscle exercise and posture.

It is perfectly reasonable to ask direct questions about those stimuli which you think might affect a pain if the initial description has indicated its source.

Radiation and referral Radiation Radiation is the extension of the pain to another site whilst the initial pain persists. For exam- ple, patients with a posterior penetrating duodenal ulcer usually have a persistent pain in the epigas- trium, but sometimes the pain spreads through the abdomen to the back. The extended pain usually has the same character as the initial pain.

A pain may occur in one site, disappear, and then reappear in another. This is not radiation: Referred pain This is a pain which is felt at a dis- tance from its source. For example, inflammation of the diaphragm will cause a pain which is felt at the tip of the shoulder. A referred pain is caused by the inability of the central nervous system to distinguish between visceral and somatic sensory impulses.

Cause It is worthwhile asking patients what they think is the cause of their pain. Even if they are hopelessly wrong, you will get some insight into their worries.

The clinical examination Sometimes a patient will be obsessed with the cause of his condition and careful questioning may reveal that he will gain or lose compensation or insurance money as the result of your opinion. Those methods of examination peculiar to each region are described in detail in the relevant chapter.

The emphasis in this introductory chapter is on the importance of taking an exact and full history, but it would not be complete without a description of the basic plan of a physical examination, with particular reference to those regions not discussed in later chapters, such as the heart, the lungs and the nervous system. As this is a thumb-nail sketch of clinical examination, your knowledge will need to be enlarged by additional reading, but your understanding and ability to solve the practical problems of clinical examination can only be clarified by frequent bedside practice.

Examine as many patients as you can. Nothing can be learnt without frequent practice. Repetition is the secret of learning.

This axiom applies as much to the doctor as it does to the sportsman or the concert pianist. Experienced clinicians rarely begin the routine physical examination without some suspicions about the diagnosis suggested by the history. Conse- quently, they often modify the impartial system- atized examination described in textbooks such as this by specifically looking for signs which confirm or refute their tentative diagnoses, but when a sign is elicited that denies their suspicions they return to the textbook routine.

Students must not do this. Although it is a practical and time-saving method in a busy clinic, and acceptable from someone with years of clinical experience who can pick out those patients to whom it can be applied, it is fundamen- tally wrong.

Bad habits grow fast enough without encouragement. Unless students discipline them- selves to use the standard textbook routine for every physical examination, many mistakes will inevitably be made and, as time passes, some parts of the examination will be completely forgotten, with seri- ous consequences.

The easiest way to ensure that you perform a complete examination is to learn the routine by heart and repeat it to yourself during the examination. Always keep to the basic pattern of looking, feeling, tapping and listening inspection, palpation, percussion, auscultation , whatever you are exam- ining.

General assessment The first part of the physical examination is per- formed when taking the history. While you are talk- ing to the patient you can observe and later record their general demeanour, their intellectual ability and intelligence, and their attitudes to their disease, to you, to their treatment, and to society in general. These observations affect the manner in which you conduct the examination.

Your instructions will need to be extremely simple if the patient is unintel- ligent, or coaxing and gentle if the patient is shy or embarrassed.Has there ever been any buzzing in the ears, dizziness or loss of speech? History taking and clinical examination 1 You must be constantly alert from the moment you first see the patient, and employ your eyes, ears, nose and hands in a systematic fashion to collect infor- mation from which you can deduce the diagnosis. If it has decreased, is this caused by a lack of desire to eat, or is it because of apprehension as eating always causes pain?

General assessment The first part of the physical examination is per- formed when taking the history. Sometimes patients try the most bizarre remedies and many convince themselves that some minor change in habit or a personal remedy has been helpful, so accept their replies to this question with caution.

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