LEVEL IV

GRAMMAR INTRODUCTION
1.Going to
We can use going to (particularly with verbs of movement) to express future action which
has been planned in advance. It also shows that the speaker feels certain that something will
happen in the future. When the future action has NOT been planned in advance but is
decided upon at the time of speaking, we normally use the Simple Future tense. Consider the
following situation and the two possible reactions:
Mrs. Smith:That's a nuisance. There's something wrong with the radio.
Mr. Smith: Yes, I knew that. I'm going to take it to the radio shop this afternoon. (Planned
in advance.)
OR

Mr. Smith: Oh, drat the thing. It's always going wrong. All right; I'll take it to the radio shop
this afternoon.
(Not planned in advance; he didn't know there was anything wrong with it.)
a. We can use am/is/are + going to for future action:
'I'm going to buy a new car at the end of the month.'

b. We can use was/were + going to to show a future intention which happened in the past:
'I was going to write to George but now I don't think I will.' We also use was/were going
to in indirect speech:
'He said he was going to buy a new car at the end of the month.
Exercise I
Rewrite these sentences, using was/were going to instead of intended to:
.1 I intended to buy a new watch but I found that I hadn't got enough money with me.
2. I know he intended to write to Mary.
3. 1 intended to wash the dishes but I forgot all about them.
4. Mary did not intend to buy the shoes at first but she changed her mind.
5. We intended to visit Peter but we were held up by the floods.
6. I intended to switch off the fan but Mary asked me to leave it on.

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 Exercise 2
Make up a possible answer or response in reply to each of the sentences below. Use
going to to show future action.
I. What are you going to do on Saturday?
2. I see you've got a puncture in that tire.
3. You haven't done the ironing yet.
4. What are you going to do this evening?
5. This switch needs repairing.
6. Your shoes need cleaning.
7. Where is your brother going to stay when he goes to London?
8. Isn't it about time you had those brakes repaired?

2. Present Continuous tense

This tense can be used to express future action which has been planned in advance. The
future time is nearly always mentioned and it is often in the near future. This usage is
particularly common in speech with such verbs as come, go, arrive, drive, fly etc.
Simple Future tense
i. I'm going to the market in a minute. Would you like to come?
ii.
In questions we must use shall before I and we.
Broadly speaking, this tense is used to express future action whether or not it is planned
in advance. Notice these points:
i. In a time clause, the Simple Present tense is used instead of the Simple Future tense: ‘I'll
pay him when I see him.'
ii. Similarly, the Simple Present tense is used instead of the Simple Future tense in a
conditional clause:
'If he comes by train, I'll meet him at the station."
iii. The Simple Future tense is often used after Do you think when a question is asked about
the future:
'Do you think it will rain this evening?'
iv. After shall or will we use the infinitive without to (e.g. pay, meet and rain in the sentences
above).
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Passive form
The passive form of the Simple Future tense is used when the action is going to be done to
the subject and not by it, e.g.
The new bridge will be formally opened on Thursday. You will be caught if you do that.

Exercise 3
Put in the passive form of the Simple Future tense of the verbs in brackets.
1. I'm sure the escaped prisoners . . . soon . . . (catch).
2. We . . . probably............................ (meet) by somebody when we arrive
at the station. Then we......................... (drive) to a hotel, I hope.
3. The repairs ................................. . .................. (finish) by five o'clock.
4. We . . ...................... probably. ....................... . (invite) to Mary's wedding.
5. The soil on the side of that hill ........................ . . soon ................... . . (wash) away.
6. Many new houses . . ................................. (build) in this town in the next few years.
7. The results of the examination ........................................ . . (announce) on Monday.
8. The prisoners ....................... . . probably.............................. . . . (release) next year.
9. I'm afraid that tree . ................ . (blow) down during the night unless the wind dies down.
10.I wonder whether I .................................................... . . (pay) at the end of the month.
11. No, I'm sure they........................................................ (not take) to Kingston tomorrow.
12.I hope the road.......................................... (repair) in time for the carnival procession

Questions with tags

These are two of the question forms of the Simple Future tense (active):
i. expecting the answer 'Yes'
He will come by train, won't he? Yes, he will.

You will write to me, won't you? Yes, I will.

ii. expecting the answer 'No'
He won't come by car, will he? No, he won't.
You won't write to her, will you? No, I won't.
Exercise 4
Complete the question and give the expected answer.
1. It won't rain, .........................?
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 2. You won't hurt yourself,.............................?
3. You will pay for me, ............................?
4. It will be open in time, .........................?
5. The men will finish tomorrow, ...........................?
6. That medicine won't make me sick, .....................?
7. Those shoes won't quite fit him, ..........................?
8. The bus will stop here, .......................................?
*9. Nobody will find out, .....................................? (Use they.)
*10. He will never manage to stop in time, ........................?

Note: *In 9 and 10 use will in your question tag because of the negative form of the
preceding statement.
Exercise 5
Change each statement into a question with a question tag, to fit the answer given in brackets.
I. He will help us. (Yes, he will.)
2. He will help them. (No, he won't.)
3. She will telephone tonight. (No, she won't.)
4. Everybody will be pleased. (Yes, they will.)
5. That fire will spread to the hedge. (No, it won't.)
6. You will remember to lock the door. (Yes, I will.)
7. The oil will leak on to the floor. (No, it won't.)
8. Your brother will probably win. (Yes, he will.)
9. The rain will come through the roof. (Yes, it will.)
10. I shall fall off. (No, you won't.)

4. Future Continuous tense

We can use the Future Continuous tense on two occasions:
a. To express action which will be in progress at some future time:
'At seven o'clock tonight I shall be doing my homework so
I shan't be able to come then.' We shall be waiting for you at five o'clock.
b. To express the future without intention, i.e. to replace the Simple Future tense
in expressing an action which will happen in the normal course of events and has
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 NOT been specially planned. Compare these sentences:
with intention: I'll make a point of seeing him about it tomorrow.
without intention: Don't worry. I usually see him every evening so I expect
I'll be seeing him tomorrow as well. Then I can tell him
about it.
Note: In a and b we can use may in place of shall or will if we wish to
express doubt, e.g. 'I may be waiting for you when you come out
of the cinema.
Exercise 6
Put in the Future Continuous form of the verb in brackets:
I. It......... probably....................... (rain) when we come out of school.
2. My sister can't come. She ............................... (iron) clothes all the afternoon.
3. What do you want to eat? I................................... (get) supper in a minute.
4. George .........................(wait) for us in his car, I expect. I hope our train is not late.
5. I ............ probably .................. (see) Mary this evening. Is there anything you want
me to tell her?
6. Peter ...........................(arrive) on the one o'clock train.
7. My brother says he ........................... (write) to you in the course of the next day or so.
8. In half an hour's time we.......................... (go) to bed but in some countries the
people ......................... just .......................(get) up.
9. We can't use the hall tomorrow evening. The Parents' Association .................... (have)
a meeting then.
10. The fishermen ........................... (pull) in their net soon. Let's go and see what's in it.

5. Simple Present tense

You may sometimes see or hear the Simple Present tense used to express future action which
has been planned in advance. often as a sequence of events:
i. He goes to London on Monday, leaves for Liverpool on Thursday and gets back here
on Saturday.
ii. The coach leaves the school at seven o'clock tomorrow morning and returns at about
six o'clock in the evening.
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This is not an important usage. The same ideas can be expressed with the Simple Future
tense, the Present Continuous tense or with going to.
6. Future Perfect tense
i. non-continuous form: shall/will have + a past participle
'I shall have finished the work by seven o'clock tonight.'
ii. continuous form: shall/will have been + a present participle 'By the end of
the year I shall have been working in the same department for exactly twenty-five years.'
The Future Perfect tense is used to express an action which will be completed or finished
by some future time or date. In many cases, the future time or date is mentioned in the
sentence and comes after 'by', as in the examples above.
Exercise 7
Put in the non-continuous form of the Future Perfect tense of the verb in brackets:
1. By the end of the year I............................................. (save) quite a lot of money.
2. If I go on at this rate, I .......................... (put) on twenty pounds by the end of the year.
Then I shall weigh more than you.
3. I am sure I....................................................... (finish) the job by tomorrow evening.
4. The man in the garage says he..................................... (complete) the overhaul of
your car by half past four.
5. We should be able to put out a good team on Saturday. Both of the injured forwards
.....................................(recover) by then.
6. Do you think the men........................ (put) in the new water-pipes by the end of the week?
7. By five o'clock this evening the space-ship...................(travel) eight times round the world.
8. We ............................................................. (use) up all the salt by the end of the week.
9. I think the tide ............................................ (turn) by seven o'clock.
10. Do you think she.............................................................(finish) the ironing by now?

SPECIAL EXAMINATIONS
SECTION 1 Instructing , explaining and reassuring
Task 1 and 2

Read the dialogue carefully between a hospital consultant, Mr. Davidson, and a patient, Mr.
Priestly. As you read, complete the case notes and decide which department the patient had
been referred to.
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DOCTOR: Good afternoon, Mr. Priestly, come in and have a seat.
PATIENT: Good afternoon, Mr. Davidson.
DOCTOR: Now I've had a letter from your doctor saying that you've
been having problems with your sight.
PATIENT: Yes, that's right doctor.
DOCTOR: Could you tell me how long the left eye has been bad for?
PATIENT: Oh, going on for about a year now, I suppose.
DOCTOR: Mm, and what do you do?
PATIENT: I'm a postman. I deliver letters and that sort of thing.
DOCTOR: How is your work being affected?
PATIENT: Oh, it's really bad. I can hardly see the letters let alone the addresses.
I have to get my mates to do that sort of thing for me and it's getting
to a stage where I just can't cope really.
DOCTOR: I see, yes. I'd just like to examine your eyes and perhaps we could
start with the chart. Could you just look at the chart for me? Can you
see any letters at all?
PATIENT: No, nothing.
DOCTOR: OK. Well, with the right eye can you see everything?
PATIENT: N H T A. That’s about all, I’m afraid.
DOCTOR: Now does that make any difference/
PATIENT: No, no nothing.
DOCTOR: What about that one? Does that have any effect?
PATIENT: Not really, I can’t really say it does.
DOCTOR: Right, Ok, thank you very much indeed.

Task 1
SURNAME ........................................ FIRST NAMES ............................................................
AGE............. SEX ..................... MARITAL STATUS ......................................
OCCUPATION..................................
PRESENT COMPLAINT
.....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
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....................................................................................................................................................
....................................................................................................................................................
Task 2

Now read again to complete the doctor's questions.

1 Can you see any letters at................................... (a)
2 Well, with the right eye...................................(b) you see........................................... (c) ?
3 Now does........................(d) make........................................(e) difference?
4 What about...............................(f) one? Does .............................. (g) have any effect?
What do you think (d) and (f) refer to?

Language focus 8
Note how the doctor starts the examination:
- I'd just like to
-Could you just... for me?
Note how the doctor indicates the examination is finished:
- Right thank you very much indeed

Task 3

You want to examine a patient. Match the examinations in the first column with the
instructions in the second column. Then practice with a partner what you would say
to patient when carrying out these examinations. Rephrase the instructions according to what
you have studied in this unit and in Unit 3. For example:

1 -d I'd just like to examine your throat. Could you please open your mouth as wide as

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 you can?
Examinations Instructions
1 the throat a) Remove your sock and shoe.
2 the ears b) Remove your top clothing.
3 the chest c) Turn your head this way.
4 the back d) Open your mouth.
5 the foot e) Tilt your head back.
6 the nasal passage f) Stand up.

Task 4

What do you think the doctor is examining by giving each of these instructions?
1 I want you to push as hard as you can against my hand.
2 Breathe in as far as you can. Now out as far as you can.
3 Say 99. Now whisper it.
4 Could you fix your eyes on the tip of my pen and keep your eyes on it?
5 I want you to keep this under your tongue until I remove it.
6 Would you roll over on your left side and bend your knees up? This may be
a bit uncomfortable.
7 I want to see you take your right heel and run it down the front of your left leg.
7 Put out your tongue. Say Aha.

Task 5

Work in pairs and look back at Task 1 Student A should start.

A: Play the part of Mr. Davidson.
1 Greet the patient.

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 2 Indicate that you have had a letter of referral.
3 Ask about the duration of the problem.
4 Ask about the patient's occupation.
5 Ask about the effect on his occupation.
6 Indicate that you would like to examine him.
7 Ask him to read the chart.
8 Ask about the right eye.
9 You change the lens does it make any difference?
10 You try another one.
11 Indicate that the examination is over.
B: Play the part of Mr. Priestly. Use the case notes as prompts.

Tasks 6 and 7

This dialog is based on an examination. As you read, tick off the systems examined.
DOCTOR: Now, Debbie, can I have a look at you to find out where your bad cough
is coming from?
PATIENT: ( Nods)
DOCTOR: Would you like to stay sitting on Mum's knee?
PATIENT: (Nods)
DOCTOR That's fine. Now let's ask Mum to take off your jumper and blouse.
You'll not be cold in here. (Mother removes Debbie’s clothes) Now
I'm going to put this thing on your chest. It's called a stethoscope. It might
be a bit cold. I'll warm it up. Feel the end there. OK? First of all I listen
to your front and then your back.
MOTHER: She's had that done lots of times by Dr Stuart.
DOCTOR: Good, well done, you didn't move at all. Now I'd like to see your tummy, so
will you lie on the bed for a minute? Will I guess what's in your tummy this
morning? I bet it's Rice Krispies.
PATIENT: (Nods)
DOCTOR: Now while you're lying there, I'll feel your neck and under your arms. Are you
tickly? Now the top of your legs. That's all very quick, isn't it? Mrs. Thomson,

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 could Debbie sit on your knee again? I'd like you to hold her there while I
examine her ears and throat. Right, Debbie. Here's a little light to look in your
ears. This will tickle a bit but won't be sore. Good girl. What a nice ear. Now
let's see the other one. Now nearly the last bit. Open your mouth. Let me see
your teeth. Now open it as wide as you can. Good. I wonder how tall you are,
Debbie. Could you come and stand over here and I'll measure you? Stand
straight. That's fine. Have you ever been on a weighing machine? Just stand up
here and we'll see how heavy you are. Well, we're all finished now. You've
been very good. I'll have a talk with your Mum and you can play with the toys
for a min
Task 6

You will read an extract from an examination. As you read, tick off the Systems examined.
System Examined
ENT ..................................
RS ..................................
CVs ..................................
GIs ..................................
GUS ..................................
CNS ...................................
Others (specify ) ...................................

What kind of examination is this?

How old do you think the patient is?
How do you know?

Language focus 9
Note how the doctor carefully reassures the patient by explaining what she is going to do
and indicating that everything is all right:
- Can I have a look at you to find out where your bad cough is coming from?
- That’s fine.

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Task 7

Try to complete the doctor's explanations and expressions of reassurance by

adding one word in each gap.

Now read the extract again and check your answers.

1 Now I'm ................................................. (a) to put this thing on your chest.

2 It ...............................................................(b) a stethoscope.
3 It .............................................................. c) be a bit cold.
4 OK? First.................................(d) all, I listen .........................................(e) your front and
....................................... (f) your back.
5 Well ...........................................(g), you didn't move at all.
6 Now I'd .....................................(h) to see your tummy...........................(I) will
you lie on the bed for a minute?
7 Now while .......................(j) lying there................................ (k) feel your neck and
under your arms.
8 Are you ....................................... (1)?
9 ............................................(m) the top of your legs.
10 That's ...............................(n) very quick..................................(o) it?

Task 8
Look back to Task 4. How would you rephrase the instructions for a 4-year-old?
When you have finished, look at the Key and read the dialog again.

5 foot
DOCTOR: We'll just ask Mummy to take off your shoes and socks so I can
have a quick look at your feet. It might be tickly but it won't be sore.

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 6 nasal passage
DOCTOR: Can you sit on Mummy's knee? I'm going to have a look at your
nose with this little light. You won't feel anything at all. Can you
put you head back to help

Section 2 Rephrasing, encouraging and prompting

Task 9
The form below is used to measure mental impairment. Discuss with a partner:
- in what order you might ask these questions
- in what form you might ask them
ISAACS-WALKEY MENTAL IMPAIRMENT MEASUREMENT
Date of test / I
Ask the patient the following questions.
Score 1 for a correct answer, 0 for an error.
Score
1 What is the name of this place? .............................
2 What day of the week is it today? .............................
3 What month is it? .............................
4 What year is it? .............................
5 What age are you? (allow ±1 year error) .............................
6 In what year were you born? .............................
7 In what month is your birthday? .............................
8 What time is it? (allow ± hour error) .............................
9 How long have you been here? (allow 25% error) .............................
Total score ............................

Significance of score
8 or 9 No significant impairment
5 to 7 Moderate impairment
1 to 4 Severe impairment
0 Complete failure
Signature of examiner .....................................................

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Tasks 10,11,12 and 13

DOCTOR: Hello, Mr. Walters. How are you today?

PATIENT: Oh, I'm fine, very well, thank you.
DOCTOR: You know who I am, don't you?
PATIENT: Now, let me see now. T know your face, but I can't quite place who you are.
I think I know. I think I should know who you ate.
DOCTOR: Well, that's tight. I'm Dr Williams. I've met you several
times before, you know.
PATIENT: Oh, you're the doctor. Well, I remember old Dr Horsburgh quite well.
I remember when he had a surgery down in the old Kirkgate, but I
don't remember seeing him recently.
DOCTOR: No, Dr Horsburgh's been retired for a good number of years now.
I took over his practice and I've seen you before. Maybe you don't recall that.
Have you been here long?
PATIENT: Where, where do you mean? ,
DOCTOR: In this house, have you been here long?
PATIENT: Oh, I've been here some time I think.
DOCTOR: Do you remember where this is? Where is this place?
PATIENT: This'll be the High Street, isn't it?
DOCTOR: Yes, this is the High Street. How long have you been living in the High Street?
PATIENT: Oh, it must be a good number of years now. I, my mother used to stay down
in North High Street of course, and I used to stay with her, but when I got
married I moved up here. Oh, that must be a good number of years. I can't
quite remember the time.
DOCTOR: Do you remember when you were born? What was the year of your birth?
Can you remember that?
PATIENT: Oh, yes. I was born in 1913.
DOCTOR: Oh, what month were you born in? Do you remember that?
PATIENT: Oh, yes. I'm an April baby. I was always an April baby. Not an April fool,
not the 1st of April you know.

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DOCTOR: Do you remember what time of the month? What was the date?
PATIENT: Oh, it was the 17th of April.
DOCTOR: Well, how old will you be now, do you think?
PATIENT: Oh, I've retired now. I must be about 69, I think. I'll be about 69.
DOCTOR: Well, there's no doubt the years go by. What year is it this year? Do you
know that?
PATIENT: Well, this'll be about 1989 now, I suppose.
DOCTOR: Fine, and what month are we in?
PATIENT: Oh, now let me see. It'll be, the, I can't, can't remember, doctor.
DOCTOR: Well, tell me, Is It summer or winter?
PATIENT: Oh, well I suppose it's so cold it must be the winter time. It'll be January.
Is that right?
DOCTOR: Well, actually it's February now, but it feels as though it was January, doesn't
it? Do you remember what day of the week it is? Or do the days not mean a
great deal to you now that you're not working?
PATIENT: Oh, you're right the days seem to run into each other, but this'll be Tuesday,
I think. No, no it'll be Wednesday, isn't it?
DOCTOR: Well, I suppose that Wednesday or Thursday, one day tends to become much
the same as the other when we're not working. Isn't that right?
PATIENT: Oh, you're right there

Task 10

You will read a dialogue between a doctor and a patient he has known for
years. As you read, number the questions above in the order they are asked. Compare the
order with your predictions.

Complete Task 11 before you check your answers in the Key.

Task l1
Study the information about the patient given below.
Then read the dialog again with the purpose of giving the patient a score.

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 SURNAME ..................................... FIRST NAMES ..John...Edward.....................................
AGE.................... SEX ............................. MARITAL STATUS...W...................................

OCCUPATION ..Retired millworker..

Date of test: Thursday 27 February 1997

Patient's DOB: 17 April 1913
How does your score compare with that given by your partner and in the Key?

Language focus 10
Note how the doctor uses a rephrasing technique to encourage the patient and give him time
to answer. For example:
Question 9: Have you been here long?
In this house, have you been here long?
How long have you been living in the High Street?
Note also that the rephrased question is often preceded by an expression like Do you
remember...? For example:
-Do you remember where this is? Where is this place?

Task l2

Predict the missing words in these extracts. Several words are required in most of the gaps.
Then read again the dialog check your predictions. Try to match the rephrasings with the
corresponding test questions. Example (a) is done for you.
a) Question ..6...... : Do you remember when you were born?
What.................................................................... (1)?
Can you .............................................................. (2)?
h) Question ...... : Do you remember what time of the month?
What ................................................................... (3)?
c) Question ........ : How old will you be now ............................................. (4)?
d) Question ........ : What year is it this year? Do you ........................................(5)?

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 e) Question ........ : Fine, and what month are we in?
Well ...................................................................... (6)?
f) Question ........ : Do you remember what day of ....................................the week it is?
Or do the ............................................... (7) now that you're
.................................................... (8)

Task 13 and Language focus 11

Part 1
DOCTOR: I now want to test how well you can feel things on the skin. I'm going to
ask you to close your eyes and say 'yes' each time you feel me touching
the skin of your legs with this small piece of cotton wool.
PATIENT: Uhuh.
DOCTOR: I'll touch the hack of your hand with it now. Do you feel that?
PATIENT: Yes, doctor.
DOCTOR: Well every time you feel me touch your legs say 'yes'.

Part 2
DOCTOR: Well, that was quite easy, wasn't it? Now I'm going to try something
a little different. I have this sharp needle with this blunt end. I want
you to say 'sharp' or blunt' each time you feel me touch.
Part 3
DOCTOR: The other sensation I want to test is whether you feel this tube hot or
this other tube which is cold. Remember I want you to keep your
eyes closed, an each time I touch the skin of your legs I want you to
tell me whether it's hot or cold.
PATIENT: Right.
Part 4
DOCTOR: Next I'm going to test you with this vibrating fork. I'm going to press
it on the ankle hone and I watt you to tell me whether you feel it vibrating,
and if you do, to say 'stop' when you feel it's stopped.

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Task 13
Mr. Jameson was referred to a neurologist for examination. During the examination the
neurologist touches Mr. Jameson with:
a) a needle
b) a piece of cotton wool
c) hot and cloth tubes
d)a vibrating fork
Read the dialog carefully from part 1 to part 4 and number the steps in the order that
the neurologist carries out them.

Note how the neurologist explains what she is going to do in Part 1 of the examination.
----I now want to ...
--- I’m going to ...
--- I’ll
a) How the doctor instructs the patient.
b)How the doctor marks the stages of her examination.
To instruct the patient, she uses:
--- I want you to...

To mark the stages of her examination, she says:

-- Now I’m going to tell something...
-Next I’m going to test you

Task 14

Using the expressions studied in Language focus 11, explain to Mr. Jameson each stage of
the examination and instruct him.

Task 15

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Part 5

DOCTOR: I’m now going to test the pulses in your legs. First we’ll press on the
blood vessel here in the groin. An now behind the knee. Could you bend it a
little for me?
PATIENT: Mm, sorry.
DOCTOR: And here behind the ankle bone. And now at the top of the foot. And now
the other leg.

The neurologist then examines Mr. Jameson’s leg pulses. The sequence of examination is a
follows.
1. the groin
2. behind the knee
3. behind the ankle bone
4. the top of the foot
5. the other leg
Write what you would say to Mr. Jameson. Then read Part 5 of the examination in the dialog
to compare.

Task 16
Work in pairs. Choose a specialist examination in your own field. Together decide how you
can explain to the patient each stage of the examination and how you would instruct the
patient. Then find a new partner to play the patient.

SECTION 3 READING SKILLS: Reading articles 1

Task 17

Here are the headings that are commonly used in articles from American journals.
Number them in the order that you would expect them to feature.

References
Summary
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Comment
Materials and methods
Authors
Editor's note
Title
Results
Introduction

Task 18
Here are some brief extracts from an article that featured in the Archives of Paediatric and
Adolescent Medicine. Try to match them to the headings given in Task 20. What features
of the text helped you to identify the parts?
Now put the headings in the order that you would expect to find them.
a)
Kathi J Kempel; MD, MPH; Paul L. McCarthy, MD; Domenic V Ciechetti, PhD

c)
1. Standards of Reporting Trials Group. A proposal for structured reporting of randomized
controlled trials.
JAMA. 1094; 272.1926-1931.
2. Working Group on Recommendations for Reporting Clinical Trials me Biomedical
Literature. Call for comments on a proposal to improve reporting of clinical trials in the
biomedical literature. Ann Intern AW 1994; 121: 694~95.
3. Hanes RB, Muriel CO, Ute .J, Altoona 06, Gardner M~. M~ informative abstracts
revisited. Ann Intern Med. 1990; 113: 69-7t.
4. Purpose and procedure. ACP J Club. 1991; 115 (supple 2): A13-A14.

b)
Abstract scoring and selection remained constant throughout the study years. All abstracts
were rated anonymously, the authors' names and institutions were omitted. All abstracts were
rated from 1 to 5, with 1 indicating unsuitable for presentation; 2, consider only if necessary;
3, borderline; 4, good; 5, a must". The ratings for each abstract were averaged. Abstracts
were sorted by rank, with the highest average scores at the top. The top abstracts were
selected for platform (oral) presentation. As space allowed, the next highest-scoring
abstracts were selected for poster presentation.
Between 1990 and 1991, the number of reviewers per abstract was reduced
from 1to six. In 1995, the pool of reviewers was expanded to include the chairpersons of
two slogs-ER and BEH and 10 regional chairpersons (RCA). Abstracts were divided into
three categories: ER, BEH, and OP The ER abstracts were reviewed by the chairperson of
the ER SIG, two RCA, and one member of the BOD. The DEH abstracts were reviewed by
20
 the chairperson of the BEH 510, two RCA, and two members of the BOD. The OP
abstracts were reviewed by five members of the BOD and six RC so every abstract was
reviewed by
at least five ratters. Specific assignments were made randomly by administrative staff
at the APA office

d)
The number of abstracts submitted and selected for presentation in 1990, l9~, 1993, and
1995 are given in Table 1. Data from 1991 and 1993 are include4 comparison.
The number of abstracts submitted for consideration for presentation at the annual APA
meeting increased steadily between 1990 and 1995. The increase capacity for poster
presentations each year since 1 increased the overall acceptance rate from 42% in I when 14
posters were presented to 62% in 1995, w 182 posters were presented. The number of oral
presentations remained constant at about 90 per year since late 19805.
Of all abstracts submitted to APA in 1995, were reviewed by the UP committee (11
reviewers), were reviewed by the ER committee (four reviewers and 43 were reviewed by the
BEH committee reviewers). There were no reported logistical problernt4 a result of
increasing the number and variety ~ reviewers. All reviews were returned within 10 days.

e)
A few cannot agree. Add more, and they also cannot agree. If not reliable able, at least they
are consistent. Perhaps this should be entitled 'Raters of the Lost Art".
Catherine D. dingles, MD

f)
These results are consistent with previous studies of the peer review process indicating that
after correcting for chance, interrupter agreement is poor. Without specific criteria and
training for reviewers, interrupter agreement is only slightly better than chance. This is also
true for evaluating funding proposals23 and in clinical medicine.24 Interrater agreement on the
quality of patient care often shows c values less than 0.40.25

g)
PEER REVIEW is a cornerstone of modern scientific process. It is the means by which grant
applications are selected for funding, experiments involving human subjects are approved,
manuscripts are selected for publication, and abstracts are selected for presentation at
scientific meetings. Research presentations help disseminate new knowledge and may
improve patient care, health services, and health education. Through abstract presentations
new researchers are introduced to the academic community and career development is
enhanced. Failure to be accepted for presentation often has damaging effects on junior
investigators' self-esteem and interest in a research career.

h)
Improving Participation and Interrater Agreement in Scoring Ambulatory Paediatric
Association Abstracts

21
How Well Have We Succeeded?

Task 19

Usually the part of the article that one reads first is the abstract or the summary. In
American journals it usually comprises four parts:
Conclusions
Methods
Objective(s)
Results

Put the headings in the order you would expect them to appear.

Task 20

Here is the Summary of the article from Task 16. Complete the text by putting in the
appropriate headings and missing words. Each gap can be completed by adding either one
word, or one word plus an article (the, a or an).
.................................(1): To determine whether increasing the number and types of
interrater agreement in scoring abstracts submitted ................................ (2) Ambulatory
Paediatric Association.
......................... (3): In 1990, all abstracts were rated by each .............................
(4)11 members of the board of directors..................................... (5) Ambulatory Paediatric
Association. In 1995, abstracts were reviewed ...................................... (6) four to five
raters, including eight members of the board of directors, two chairpersons of special
interest groups, and ten regional chair persons, for a total of 20 potential reviewers.
Submissions were divided into the following three categories ................................. (7)
review: emergency medicine, behavioural paediatrics, and general paediatrics. Weighted
percentage agreement and weighted K scores were computed for 1990 and 1995 abstract
scores.
..................................... (8): Between 1990 and 1995, the number of abstracts submitted
.........................................(9) Ambulatory Paediatric Association increased from 246 to 407,
the number ....................... (10) reviewers increased from 11 to 20, the weighted percentage
agreement between raters remained approximately 79% and weighted K scores remained less
...........................(11) 0.25. Agreement was not significantly better for the emergency
medicine and behavioural abstracts than for general paediatrics........................ (12) was it
22
 better for the raters ................................. (13) reviewed fewer abstracts than those who
reviewed many. ............................... (14): The number and expertise ......................... (15)
those rating abstracts increased from 1990 to 1995. ..................................... (16), interrater
agreement did ..............................(17) change and remained low. Further efforts are needed
............................(18) improve the interrater agreement.

Think about some of the journal articles that you regularly read. Do they follow the same
structure, or are there some differences? Compare notes with a partner or other members of
your group.
If you have the opportunity to visit the medical library, or a library that has some medical and
scientific journals and compare their structures. How do they compare with the structures of
journal articles written in your mother tongue?

Section 4 Case history: William Hudson

Task 21

Mr. Hudson was put on a waiting list for a TUR following his consultation with Mr. Fielding.
However, after five weeks he was admitted to hospital as an emergency.
Study the registrar's case notes on Mr. Hudson following his admission.

PRESENT COMPLAINT
Unable to PU for 24 hrs
In sever pain
Awaiting TUR for enlarged prostate

OIE
General Condition Restlessness due to pain
Sweating ++
ENT
RS chest clear

23
CVS P120 AF

BP 180/120 HS I, II no murmurs
GIS bladder distended to umbilicus

GUS PR prostate enlarged, soft

CNS NAD

DIAGNOSIS
(!) Acute retention due to prostate hypertrophy
(2) Atrial fibrillation ? cause

MANAGEMENT
Sedate
Catheterise
Ask physician to see him

The following notes were added after catheterization

INVESTIGATIONS
Urinalysis 3+ sugar

MANAGEMENT
Rx digoxin 0.25 mg daily
Metformin 500 mg t.d.s

What addition would you make to the Diagnosis section?

Write a letter to Mr. Hudson's doctor, Dr Watson, explaining your findings.

24
 READING COMPREHENSION AND DISCUSSION
TOPICS
TEACHER’S DISCRECTION

I INTRODUCTION

Brain (medicine), portion of the sleep, hunger, thirst, and virtually

central nervous system contained every other vital activity necessary
within the skull. The brain is the to survival. All human emotions—
control centre for movement, including love, hate, fear, anger,
elation, and sadness—are
controlled by the brain. It also
receives and interprets the
25
countless signals that are sent to it brain makes us conscious,
from other parts of the body and emotional, and intelligent.
from the external environment. The

The human brain has three major structural components: the large
dome-shaped cerebrum (top), the smaller somewhat spherical
cerebellum (lower right), and the brainstem (centre). Prominent in the
brainstem are the medulla oblongata (the egg-shaped enlargement at
centre) and the thalamus (between the medulla and the cerebrum).
The cerebrum is responsible for intelligence and reasoning. The
cerebellum helps to maintain balance and posture. The medulla is
involved in maintaining involuntary functions such as respiration, and
the thalamus acts as a relay centre for electrical impulses travelling to
and from the cerebral cortex.

II ANATOMY
The adult human brain is a 1.3-kg (3-lb) mass of pinkish-gray jellylike tissue
made up of approximately 100 billion nerve cells, or neurones; neuroglia
(supporting-tissue) cells; and vascular (blood-carrying) and other tissues.

Between the brain and the cranium—the part of the skull that directly covers
the brain—are three protective membranes, or meninges. The outermost
membrane, the dura mater, is the toughest and thickest. Below the dura mater
is a middle membrane, called the arachnoid layer. The innermost membrane,
the pia mater, consists mainly of small blood vessels and follows the contours
of the surface of the brain.

26
A clear liquid, the cerebrospinal fluid, bathes the entire brain and fills a series
of four cavities, called ventricles, near the centre of the brain. The
cerebrospinal fluid protects the internal portion of the brain from varying
pressures and transports chemical substances within the nervous system.

From the outside, the brain appears as three distinct but connected parts: the
cerebrum (the Latin word for brain)—two large, almost symmetrical
hemispheres; the cerebellum ("little brain")—two smaller hemispheres located
at the back of the cerebrum; and the brain stem—a central core that gradually
becomes the spinal cord, exiting the skull through an opening at its base called
the foramen magnum. Two other major parts of the brain, the thalamus and the
hypothalamus, lie in the midline above the brain stem underneath the
cerebellum.
The brain and the spinal cord together make up the central nervous system,
which communicates with the rest of the body through the peripheral nervous
system. The peripheral nervous system consists of 12 pairs of cranial nerves
extending from the cerebrum and brain stem; a system of other nerves
branching throughout the body from the spinal cord; and the autonomic nervous
system, which regulates vital functions not under conscious control, such as the
activity of the heart muscle, smooth muscle (involuntary muscle found in the
skin, blood vessels, and internal organs),

A Cerebrum

27
Most high-level brain functions take separated by small grooves called
place in the cerebrum. Its two large sulci and larger grooves called
hemispheres make up fissures. Approximately two-thirds
approximately 85 percent of the of the cortical surface is hidden in
brain's weight. The exterior surface the folds of the sulci. The extensive
convolutions enable a very large
surface area of brain cortex—about
1.5 m2 (16 ft2) in an adult—to fit
within the cranium. The pattern of
these convolutions is similar,
although not identical, in all
humans.

The two cerebral hemispheres are

of the cerebrum, the cerebral
partially separated from each other
cortex, is a convoluted, or folded,
by a deep fold known as the
grayish layer of cell bodies known
longitudinal fissure.
as the gray matter. The gray
Communication between the two
matter covers an underlying mass
hemispheres is through several
of fibers called the white matter.
concentrated bundles of axons,
The convolutions are made up of
called commissures, the largest of
ridgelike bulges, known as gyri,
which is the corpus callosum.

Several major sulci divide the cortex into distinguishable regions. The central
sulcus, or Rolandic fissure, runs from the middle of the top of each hemisphere
downward, forward, and toward another major sulcus, the lateral ("side"), or
Sylvian, sulcus. These and other sulci and gyri divide the cerebrum into five
lobes: the frontal, parietal, temporal, and occipital lobes and the insula.

The frontal lobe is the largest of the

five and consists of all the cortex in
28
front of the central sulcus. Broca's area, a part of the cortex related to
speech, is

located in the frontal lobe. The cerebrum. The temporal lobe is to

parietal lobe consists of the cortex the side of and below the lateral
behind the central sulcus to a sulcus. Wernicke's area, a part of
sulcus near the back of the the cortex related to the
cerebrum known as the parieto- understanding of language, is
occipital sulcus. The parieto- located in the temporal lobe. The
occipital sulcus, in turn, forms the insula lies deep within the folds of
front border of the occipital lobe, the lateral sulcus.
which is the rearmost part of the

The cerebrum receives information from all the sense organs and sends motor
commands (signals that result in activity in the muscles or glands) to other
parts of the brain and the rest of the body. Motor commands are transmitted by
the motor cortex, a strip of cerebral cortex extending from side to side across
the top of the cerebrum just in front of the central sulcus. The sensory cortex, a
parallel strip of cerebral cortex just in back of the central sulcus, receives input
from the sense organs.

Many other areas of the cerebral cortex have also been mapped according to
their specific functions, such as vision, hearing, speech, emotions, language,
and other aspects of perceiving, thinking, and remembering. Cortical regions

known as associative cortex are responsible for integrating multiple inputs,

processing the information, and carrying out complex responses.

B Cerebellum The cerebellum coordinates body movements.

Located at the lower back of the brain beneath the occipital lobes, the
cerebellum is divided into two lateral (side-by-side) lobes connected by a
fingerlike bundle of white fibers called the vermis. The outer layer, or cortex, of
the cerebellum consists of fine folds called folia. As in the cerebrum, the outer
layer of cortical gray matter surrounds a deeper layer of white matter and
nuclei (groups of nerve cells). Three fiber bundles called cerebellar peduncles
29
connect the cerebellum to the three parts of the brain stem—the midbrain, the
pons, and the medulla oblongata.

The cerebellum coordinates voluntary movements by fine-tuning commands

from the motor cortex in the cerebrum. The cerebellum also maintains posture
and balance by controlling muscle tone and sensing the position of the limbs.
All motor activity, from hitting a baseball to fingering a violin, depends on the
cerebellum.

C Thalamus and Hypothalamus The thalamus and the

hypothalamus lie underneath the cerebrum and connect it to the brain stem.
The thalamus consists of two rounded masses of gray tissue lying within the
middle of the brain, between the two cerebral hemispheres. The thalamus is
the main relay station for incoming sensory signals to the cerebral cortex and
for outgoing motor signals from it. All sensory input to the brain, except that of
the sense of smell, connects to individual nuclei of the thalamus.

The hypothalamus lies beneath the thalamus on the midline at the base of the
brain. It regulates or is involved directly in the control of many of the body's
vital drives and activities, such as eating, drinking, temperature regulation,
sleep, emotional behavior, and sexual activity. It also controls the function of
internal body organs by means of the autonomic nervous system, interacts
closely with the pituitary gland, and helps coordinate activities of the brain
stem.

D Brain Stem
The brain stem is evolutionarily the
most primitive part of the brain and
is responsible for sustaining the
basic functions of life, such as
breathing and blood pressure. It
includes three main structures

30
lying between and below the two midbrain, pons, and medulla
cerebral hemispheres—the oblongata

D1 Midbrain The topmost structure of the brain stem is the

midbrain. It contains major relay stations for neurons transmitting signals to

the cerebral cortex, as well as many reflex centres—pathways carrying sensory
(input) information and motor (output) commands. Relay and reflex centres for
visual and auditory (hearing) functions are located in the top portion of the
midbrain. A pair of nuclei called the superior colliculus control reflex actions of
the eye, such as blinking, opening and closing the pupil, and focusing the lens.
A second pair of nuclei, called the inferior colliculus, control auditory reflexes,
such as adjusting the ear to the volume of sound. At the bottom of the
midbrain are reflex and relay centres relating to pain, temperature, and touch,
as well as several regions associated with the control of movement, such as the
red nucleus and the substantia nigra.

D2 Pons Continuous with and below the midbrain and directly in

front of the cerebellum is a prominent bulge in the brain stem called the pons.
The pons consists of large bundles of nerve fibers that connect the two halves
of the cerebellum and also connect each side of the cerebellum with the
opposite-side cerebral hemisphere. The pons serves mainly as a relay station
linking the cerebral cortex and the medulla oblongata.

D3 Medulla Oblongata The long, stalklike lowermost portion of the

brain stem is called the medulla oblongata. At the top, it is continuous with the
pons and the midbrain; at the bottom, it makes a gradual transition into the
spinal cord at the foramen magnum. Sensory and motor nerve fibers
connecting the brain and the rest of the body cross over to the opposite side as
they pass through the medulla. Thus, the left half of the brain communicates
with the right half of the body, and the right half of the brain with the left half
of the body.
31
D4 Reticular Formation Running up the brain stem from the medulla

oblongata through the pons and the midbrain is a netlike formation of nuclei
known as the reticular formation. The reticular formation controls respiration,
cardiovascular function (see Heart), digestion, levels of alertness, and patterns
of sleep. It also determines which parts of the constant flow of sensory
information into the body are received by the cerebrum.

E Brain Cells There are two main types of brain cells: neurons and

neuroglia. Neurons are responsible for the transmission and analysis of all
electrochemical communication within the brain and other parts of the nervous
system. Each neuron is composed of a cell body called a soma, a major fiber
called an axon, and a system of branches called dendrites. Axons, also called
nerve fibers, convey electrical signals away from the soma and can be up to 1
m (3.3 ft) in length. Most axons are covered with a protective sheath of myelin,
a substance made of fats and protein, which insulates the axon. Myelinated
axons conduct neuronal signals faster than do unmyelinated axons. Dendrites
convey electrical signals toward the soma, are shorter than axons, and are
usually multiple and branching.

Neuroglial cells are twice as numerous as neurons and account for half of the
brain's weight. Neuroglia (from glia, Greek for "glue") provide structural
support to the neurons. Neuroglial cells also form myelin, guide developing
neurons, take up chemicals involved in cell-to-cell communication, and
contribute to the maintenance of the environment around neurons.

F Cranial Nerves Twelve pairs of cranial nerves arise symmetrically

from the base of the brain and are numbered, from front to back, in the order in
which they arise. They connect mainly with structures of the head and neck,
such as the eyes, ears, nose, mouth, tongue, and throat. Some are motor
nerves, controlling muscle movement; some are sensory nerves, conveying
information from the sense organs; and others contain fibers for both sensory
and motor impulses. The first and second pairs of cranial nerves—the olfactory
(smell) nerve and the optic (vision) nerve—carry sensory information from the

32
nose and eyes, respectively, to the undersurface of the cerebral hemispheres.
The other ten pairs of cranial nerves originate in or end in the brain stem.

III HOW THE BRAIN WORKS

The brain functions by complex neuronal, or nerve cell, circuits (see
Neurophysiology). Communication between neurons is both electrical and
chemical and always travels from the dendrites of a neuron, through its soma,
and out its axon to the dendrites of another neuron.

Dendrites of one neuron receive signals from the axons of other neurons
through chemicals known as neurotransmitters. The neurotransmitters set of
electrical charges in the dendrites, which then carry the signals
electrochemically to the soma. The soma integrates the information, which is
then transmitted electrochemically down the axon to its tip.

At the tip of the axon, small, bubblelike structures called vesicles release
neurotransmitters that carry the signal across the synapse, or gap, between
two neurons. There are many types of neurotransmitters, including
norepinephrine, dopamine, and serotonin. Neurotransmitters can be excitatory
(that is, they excite an electrochemical response in the dendrite receptors) or
inhibitory (they block the response of the dendrite receptors).

One neuron may communicate with thousands of other neurons, and many
thousands of neurons are involved with even the simplest behavior. It is
believed that these connections and their efficiency can be modified, or
altered, by experience.

Scientists have used two primary approaches to studying how the brain works.
One approach is to study brain function after parts of the brain have been
damaged. Functions that disappear or that are no longer normal after injury to
specific regions of the brain can often be associated with the damaged areas.
The second approach is to study the response of the brain to direct stimulation
or to stimulation of various sense organs.

Neurons are grouped by function into collections of cells called nuclei. These
nuclei are connected to form sensory, motor, and other systems. Scientists can
33
study the function of somatosensory (pain and touch), motor, olfactory, visual,
auditory, language, and other systems by measuring the physiological
(physical and chemical) changes that occur in the brain when these senses are
activated. For example, electroencephalography (EEG) measures the electrical
activity of specific groups of neurons through electrodes attached to the
surface of the skull. Electrodes inserted directly into the brain can give
readings of individual neurons. Changes in blood flow, glucose (sugar), or
oxygen consumption in groups of active cells can also be mapped.

Although the brain appears symmetrical, how it functions is not. Each

hemisphere is specialized and dominates the other in certain functions.
Research has shown that hemispheric dominance is related to whether a
person is predominantly right-handed or left-handed (see Handedness). In most
right-handed people, the left hemisphere processes arithmetic, language, and
speech. The right hemisphere interprets music, complex imagery, and spatial
relationships and recognizes and expresses emotion. In left-handed people, the
pattern of brain organization is more variable.

Hemispheric specialization has traditionally been studied in people who have

sustained damage to the connections between the two hemispheres, as may
occur with stroke, an interruption of blood flow to an area of the brain that
causes the death of nerve cells in that area. The division of functions between
the two hemispheres has also been studied in people who have had to have
the connection between the two hemispheres surgically cut in order to control
severe epilepsy, a neurological disease characterized by convulsions and loss
of consciousness.

A Vision The visual system of humans is one of the most advanced

sensory systems in the body (see Vision). More information is conveyed visually
than by any other means. In addition to the structures of the eye itself, several
cortical regions—collectively called primary visual and visual associative cortex
—as well as the midbrain are involved in the visual system. Conscious
processing of visual input occurs in the primary visual cortex, but reflexive—
that is, immediate and unconscious—responses occur at the superior colliculus
34
in the midbrain. Associative cortical regions—specialized regions that can
associate, or integrate, multiple inputs—in the parietal and frontal lobes along
with parts of the temporal lobe are also involved in the processing of visual
information and the establishment of visual memories.

B Language Language involves specialized cortical regions in a

complex interaction that allows the brain to comprehend and communicate

abstract ideas. The motor cortex initiates impulses that travel through the
brain stem to produce audible sounds. Neighboring regions of motor cortex,
called the supplemental motor cortex, are involved in sequencing and
coordinating sounds. Broca's area of the frontal lobe is responsible for the
sequencing of language elements for output. The comprehension of language
is dependent upon Wernicke's area of the temporal lobe. Other cortical circuits
connect these areas.

C Memory Memory is usually considered a difusely stored associative

process—that is, it puts together information from many diferent sources.

Although research has failed to identify specific sites in the brain as locations of
individual memories, certain brain areas are critical for memory to function.
Immediate recall—the ability to repeat short series of words or numbers
immediately after hearing them—is thought to be located in the auditory
associative cortex. Short-term memory—the ability to retain a limited amount
of information for up to an hour—is located in the deep temporal lobe. Long-
term memory probably involves exchanges between the medial temporal lobe,
various cortical regions, and the midbrain.

D The Autonomic Nervous System

The autonomic nervous system regulates the life support systems of the body
reflexively—that is, without conscious direction. It automatically controls the
muscles of the heart, digestive system, and lungs; certain glands; and
homeostasis—that is, the equilibrium of the internal environment of the body
(see Physiology). The autonomic nervous system itself is controlled by nerve
centres in the spinal cord and brain stem and is fine-tuned by regions higher in
35
the brain, such as the midbrain and cortex. Reactions such as blushing indicate
that cognitive, or thinking, centres of the brain are also involved in autonomic
responses.

IV BRAIN DISORDERS
The brain is guarded by several highly developed protective mechanisms. The
bony cranium, the surrounding meninges, and the cerebrospinal fluid all
contribute to the mechanical protection of the brain. In addition, a filtration
system called the blood-brain barrier protects the brain from exposure to
potentially harmful substances carried in the bloodstream.

Brain disorders have a wide range of causes, including head injury, stroke,
bacterial diseases, complex chemical imbalances, and changes associated with
aging.

A Head Injury Head injury can initiate a cascade of damaging

events. After a blow to the head, a person may be stunned or may become
unconscious for a moment. This injury, called a concussion, usually leaves no
permanent damage. If the blow is more severe and hemorrhage (excessive
bleeding) and swelling occur, however, severe headache, dizziness, paralysis, a
convulsion, or temporary blindness may result, depending on the area of the
brain afected. Damage to the cerebrum can also result in profound personality
changes.

Damage to Broca's area in the frontal lobe causes difficulty in speaking and
writing, a problem known as Broca's aphasia. Injury to Wernicke's area in the
left temporal lobe results in an inability to comprehend spoken language, called
Wernicke's aphasia.

An injury or disturbance to a part of the hypothalamus may cause a variety of

diferent symptoms, such as loss of appetite with an extreme drop in body
weight; increase in appetite leading to obesity; extraordinary thirst with
excessive urination (diabetes insipidus); failure in body-temperature control,
resulting in either low temperature (hypothermia) or high temperature (fever);
excessive emotionality; and uncontrolled anger or aggression. If the
36
relationship between the hypothalamus and the pituitary gland is damaged
(see Endocrine System), other vital bodily functions may be disturbed, such as
sexual function, metabolism, and cardiovascular activity.

Injury to the brain stem is even more serious because it houses the nerve
centres that control breathing and heart action. Damage to the medulla
oblongata usually results in immediate death.

B Stroke A stroke is damage to the brain due to an interruption in

blood flow. The interruption may be caused by a blood clot (see Embolism;
Thrombosis), constriction of a blood vessel, or rupture of a vessel accompanied
by bleeding. A pouchlike expansion of the wall of a blood vessel, called an
aneurysm (see Artery), may weaken and burst, for example, because of high
blood pressure.

Sufficient quantities of glucose and oxygen, transported through the

bloodstream, are needed to keep nerve cells alive. When the blood supply to a
small part of the brain is interrupted, the cells in that area die and the function
of the area is lost. A massive stroke can cause a one-sided paralysis
(hemiplegia) and sensory loss on the side of the body opposite the hemisphere
damaged by the stroke.

37
C Brain Diseases Some brain diseases, such as
multiple sclerosis and Parkinson's
disease, are progressive, becoming
worse over time. Multiple sclerosis
damages the myelin sheath around
axons in the brain and spinal cord.
Epilepsy is a broad term for a
As a result, the afected axons
variety of brain disorders
cannot transmit nerve impulses
characterized by seizures, or
properly. Parkinson's disease
convulsions. Epilepsy can result
destroys the cells of the substantia
from a direct injury to the brain at
nigra in the midbrain, resulting in a
birth or from a metabolic
deficiency in the neurotransmitter
disturbance in the brain at any
dopamine that afects motor
time later in life.
functions.

Cerebral palsy is a broad term for brain damage sustained close to birth that
permanently afects motor function. The damage may take place either in the
developing fetus, during birth, or just after birth and is the result of the faulty
development or breaking down of motor pathways. Cerebral palsy is
nonprogressive—that is, it does not worsen with time.

A bacterial infection in the cerebrum (see Encephalitis) or in the coverings of

the brain (see Meningitis), swelling of the brain (see Edema), or an abnormal
growth of healthy brain tissue (see Tumor) can all cause an increase in
intracranial pressure and result in serious damage to the brain.

Scientists are finding that certain brain chemical imbalances are associated
with mental disorders such as schizophrenia and depression. Such findings
have changed scientific understanding of mental health and have resulted in
new treatments that chemically correct these imbalances.

During childhood development, the brain is particularly susceptible to damage

because of the rapid growth and reorganization of nerve connections. Problems

38
that originate in the immature brain can appear as epilepsy or other brain-
function problems in adulthood.

Several neurological problems are common in aging. Alzheimer's disease

damages many areas of the brain, including the frontal, temporal, and parietal
lobes. The brain tissue of people with Alzheimer's disease shows characteristic
patterns of damaged neurons, known as plaques and tangles. Alzheimer's
disease produces a progressive dementia (see Senile Dementia), characterized
by symptoms such as failing attention and memory, loss of mathematical
ability, irritability, and poor orientation in space and time.

V BRAIN IMAGING
Several commonly used diagnostic methods give images of the brain without
invading the skull. Some portray anatomy—that is, the structure of the brain—
whereas others measure brain function. Two or more methods may be used to
complement each other, together providing a more complete picture than
would be possible by one method alone.

Magnetic resonance imaging (MRI), introduced in the early 1980s, beams high-
frequency radio waves into the brain in a highly magnetized field that causes
the protons that form the nuclei of hydrogen atoms in the brain to reemit the
radio waves. The reemitted radio waves are analyzed by computer to create
thin cross-sectional images of the brain. MRI provides the most detailed images
of the brain and is safer than imaging methods that use X rays. However, MRI
is a lengthy process and also cannot be used with people who have
pacemakers or metal implants, both of which are adversely afected by the
magnetic field.

Computed tomography (CT), also known as CT scans, developed in the early

1970s. This imaging method X-rays the brain from many diferent angles,
feeding the information into a computer that produces a series of cross-
sectional images. CT is particularly useful for diagnosing blood clots and brain
tumors. It is a much quicker process than magnetic resonance imaging and is

39
therefore advantageous in certain situations—for example, with people who are
extremely ill.

Changes in brain function due to brain disorders can be visualized in several

ways. Magnetic resonance spectroscopy measures the concentration of specific
chemical compounds in the brain that may change during specific behaviors.
Functional magnetic resonance imaging (fMRI) maps changes in oxygen
concentration that correspond to nerve cell activity.

Positron emission tomography (PET), developed in the mid-1970s, uses

computed tomography to visualize radioactive tracers (see Isotopic Tracer),
radioactive substances introduced into the brain intravenously or by inhalation.
PET can measure such brain functions as cerebral metabolism, blood flow and
volume, oxygen use, and the formation of neurotransmitters. Single photon
emission computed tomography (SPECT), developed in the 1950s and 1960s,
uses radioactive tracers to visualize the circulation and volume of blood in the
brain.

Brain-imaging studies have provided new insights into sensory, motor,

language, and memory processes, as well as brain disorders such as epilepsy;
cerebrovascular disease; Alzheimer's, Parkinson's, and Huntington's diseases
(see Chorea); and various mental disorders, such as schizophrenia.

VI EVOLUTION OF THE BRAIN

In lower vertebrates, such as fish and reptiles, the brain is often tubular and
bears a striking resemblance to the early embryonic stages of the brains of
more highly evolved animals. In all vertebrates, the brain is divided into three
regions: the forebrain (prosencephalon), the midbrain (mesencephalon), and
the hindbrain (rhombencephalon). These three regions further subdivide into
diferent structures, systems, nuclei, and layers.

The more highly evolved the animal, the more complex is the brain structure.
Human beings have the most complex brains of all animals. Evolutionary forces
have also resulted in a progressive increase in the size of the brain. In

40
vertebrates lower than mammals, the brain is small. In meat-eating animals,
particularly primates, the brain increases dramatically in size.

The cerebrum and cerebellum of higher mammals are highly convoluted in

order to fit the most gray matter surface within the confines of the cranium.
Such highly convoluted brains are called gyrencephalic. Many lower mammals
have a smooth, or lissencephalic ("smooth head"), cortical surface.

There is also evidence of evolutionary adaption of the brain. For example,

many birds depend on an advanced visual system to identify food at great
distances while in flight. Consequently, their optic lobes and cerebellum are
well developed, giving them keen sight and outstanding motor coordination in
flight. Rodents, on the other hand, as nocturnal animals, do not have a well-
developed visual system. Instead, they rely more heavily on other sensory
systems, such as a highly developed sense of smell and facial whiskers.

VII RECENT RESEARCH Recent research in brain function suggests

that there may be sexual diferences in both brain anatomy and brain function.
One study indicated that men and women may use their brains diferently
while thinking. Researchers used functional magnetic resonance imaging to
observe which parts of the brain were activated as groups of men and women
tried to determine whether sets of nonsense words rhymed. Men used only
Broca's area in this task, whereas women used Broca's area plus an area on the
right side of the brain.

KEY ANSWERS Special examinations

Task 1
SURNAME Priestly FIRST NAMES John

AGE 58 SEX M MARITAL STATUS M

OCCUPATION Postman

PRESENT COMPLAINT
41
Failing sight. L eye has deteriorated over past year
Seriously affecting his work – “can’t cope”

The patient has been referred to the Ophthalmology Department (the Eye Clinic).

Task 2
a) all

h) can

c) anything

d) that

e) any

f)that

g) that

(d) and (f) refer to lenses.

Task 3
1d 2c 3b 4f 5a
6e

Possible instructions:

2 I'm going to examine your ears. Could you turn your head this way?

3 I'd like to examine your chest. Could you remove your top clothing?

4 I'll just check your back. Would you stand up, please?

5 Would you like to take your shoe and sock off and I'll examine your foot.

6 If you'd like to tilt your head back, I'll just examine your nasal passage.

Task 4

1 limb power
2 lung vital capacity
3 consolidation of the lungs
4 eye movements
5 temperature
6 rectum
7 co ordination of the right limb
8 throat / tonsils

42
Task 5

Compare your version with the dialog in Task 1.

Task 6
RS, GIS, glands, ENT, height and weight.
Paediatric
The patient is a 4year-old girl (with her mother).

Task 8
a) going
b) called
c) might
d) of
t) to
f) then
g) done
li) like
i) so
) you're
k) I'll
I) sickly
m) now
n) all
o) isn't
Task 8
For paediatric examination of the throat (1), ears (2), chest (3) and back (4) see dialog Task 7
5 foot
We'll just ask Mummy to take off your shoes and socks so I can have a quick look at your
feet. It might be tickly but it won't be sore.

Nasal /passage
Can you sit on Mummy's knee? I'm going to have a look at your nose with this little light.
You won't feel anything at all. Can you put your head back to help me?

Tasks 9, 10 and 11
Test question Order Patient's score
1 1 1
2 8 0
3 7 0
4 6 0
5 5 0
6 3 1
43
 7 4 1
8 -- --
9 2 0
Total score 3/8
= severe impairment
Task 12
1 What was the year of your birth?
2 Can you remember that?
3 What was the date?
4 How old will you be now, do you think?
5 Do you know that?
6 Well tell me, is it summer or winrer?

7/8 Or do the days not mean a great deal to you now that you're not working?
b) question 7
c) question 5
d) question 4
e) question 3
f) question 2

Task 13
I What is this place called? Where are we now~
2 Which day is it today? What day is this?
3 What is this month called? What month are we in now?
4 What year are we in? What is the year?
5 How old are you? What is your age?
6 When were you born?
What was your year of birth?
7 What is your date of birth?
What month were you born in?
8 What's the time?
Can you tell me the time?
9 How many years have you been living here?
For how long have you stayed here?

Task 14
1b 2a 3c 4

Task 15

1 Title
2 Authors
3 Editor's note
4 Summary
5 Introduction
6 Materials and methods
44
7 Results
8 Comment
9 References

Task 16
Title - h
Authors - a
Editor's note - e
Introduction - g
Materials and methods - b
Results - d
Comment - f
References - c
The typeface and linguistic features such as key words and tenses help identify
the parts.

Task 17
1 Objective(s)
2 Methods
3 Results
4 Conclusions

Task 18
1 Objective
2 to the
3 Methods
4 of the
5 of the
6 by
7 for
8 Results
9 to the
10 of
11than
12 nor
13 who
14 Conclusions
15 of
16 However
17 not
18 to

Task 24

Dear Dr Watson,

Your patient, Mr Hudson, was admitted as an emergency on 23 February with acute

retention of urine due to his enlarged prostate for which he was awaiting elective surgery.

45
 On admission to the ward he was still In rapid atrial fibrillation and his blood pressure
was
180/120. The bladder was distended to the umbilicus and p.r. showed an enlarged soft
prostate.
He was sedated and catheterised. Urinalysis showed 3+ glucose and GTT showed a
diabetic curve.
He was therefore started on diet and metformin 500 mg t.d.s.

Dr Wflson, our physician, is deallrg with the cardiac side of things before we go ahead
with the operation.

Yours sincerely,

46