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You may also be required to complete one or two topic presentations—in some past years purchase cheap female viagra on line, all students have been required to complete one presentation on psychiatric aspects of a chronic disease order 100mg female viagra amex. Be extra careful about dressing professionally on psychiatry generic 100mg female viagra fast delivery; remember that cleavage or flashy clothes might give the wrong signal to a confused patient. Some helpful hints for psych: • This is the only rotation where you don’t shake your patient’s hand when you walk in the room. This means never putting the patient between you and the door, never doing anything you feel uncomfortable with, and adhering to any guidelines that your residents and attendings create. Mental Status Exam: The psych H&P is similar to the general H&P, but it is important to pay extra attention to the past psych history, family psych history, drug and alcohol history, and social history. Behavior: Include gestures, abnormal or idiosyncratic movements (akathisia, automatisms, catatonia, choreoathetoid movements, compulsions, dystonias, tardive dyskinesia, tics, tremors, etc. Cooperation/reliability: Pay attention to patients’ cooperation/attentiveness to the interview and their attitude/demeanor. Speech: Note rate, quantity, quality (volume, rhythm), and form, as well as any difficulty speaking (i. Thought Process: This is the form or structure of the patient’s thinking as opposed to the actual content. Impaired thought processes include looseness of associations, flight of ideas, word salad, thought blocking (sudden interruption of thought and speech), racing, etc. Includes delusions, suicidal/homicidal ideation, paranoia, somatic or religious pre-occupation, other obsessions, grandiosity, helplessness, ideas of reference, ideas of thought control or thought broadcasting, thought insertion, beliefs of unusual powers, phobias, fears, feelings of worthlessness or guilt, and feelings of being punished. This is the internal emotional state that you believe to be present—may not match the patient’s affect. The sites also vary in terms of hours and expectations, so try to find out from your friends about the various sites. Throughout the rotation, you will meet regularly for lectures that will cover a lot of the material you will need for the shelf. The inpatient experiences should be very similar to your core rotation in inpatient medicine in that you will help admit, work up, manage, and follow specific patients throughout the course of their admission. On a consult service, you will see how neurologic issues may affect patients on other specialty services. Presentations and notes should follow the standard format, with the addition of a directed neurologic history, comprehensive neurologic exam, and underlying appreciation for relevant neuroanatomy. You may be asked to prepare a topic presentation to present to your team—see the “Sample Documents” packet for an example of a Neurology topic presentation. With pediatric patients, keep in mind that at different ages, some aspects of the neuro exam are not applicable or need to be approached in a different manner. You may want to get a copy of the Denver developmental 51 milestones sheet to get an idea of what is appropriate behavior given a child’s age. Neurologic Exam Cranial Nerves: I: Olfactory: most do not try to test this; if you are really on top of your game, you may have a vial of something with an odor. As a student, you can stuff your white coat with a light pen, toothpicks or wooden cotton swabs, reflex hammer (or use the end of your stethoscope), tuning forks (if you really have it together), and an ophthalmoscope (if you have one or have friends from whom you can borrow one— definitely not necessary though). Ophthalmology The Ophthalmology week begins with an introductory session on the eye exam, use of the slit lamp, and looking at each other’s fundi. Be prepared to have your eye dilated and remember your ophthalmoscope, if you have one or can borrow one (but don’t worry if you don’t have one—you can share with other students). Be sure to look at these photographs as a good portion of the exam at the end of the week consists of slides from the book. You will have the opportunity to practice a complete head and neck exam on each other and see a laryngoscopy. They have recently been cracking down on attendance, so try to assess what is expected of you in the beginning of the week. You will be given a set of questions and answers covering basic orthopedic topics and the exam questions at the end of the week will be drawn directly from these questions. Surgery/ Emergency Medicine/Anesthesiology The combination of these three disciplines into a single clinical block allows for an integrated curriculum to best present clinical issues commonly encountered among practitioners in all three fields. Lectures and case- and problem-based learning sessions will address interdisciplinary topics including shock, fluids and electrolytes, hemodynamics, coagulation, peri-operative management, and trauma/critical care. Additionally, rotation-specific curricula will address topics more relevant to each discipline to compliment your clinical experience. Surgery Disclaimer: A testament to Penn’s commitment to providing the best medical education experience, the Surgery Clerkship is continually improving. Rachel Kelz, for any updates as recent changes to this clerkship may have been made after the printing of this booklet. As a 200 student you will complete one 4-week block of general surgery (graded Honors, High Pass, Pass, Low Pass, Fail) and two 2-week blocks of surgical subspecialty (graded Pass/Fail). This schedule affords most students both a broad surgical experience and a detailed view of the life of a surgeon. Please refer to the following website for up-to-date information about schedules, grading, and course logistics: http://www. In surgery it is commonplace for the sub-I to get “first cracks” at the cases particularly when the senior attending in a particular discipline is operating. That said, if you feel like you are truly getting the short end of the stick, you should approach the sub-I and discuss case selection. If you have some downtime, it is wise to offer to help the intern as they can typically use it, and it can help everyone get home earlier. Most surgery services have now switched to a night float system, which alleviates some of the intern’s burdens, but they will still be very busy and very grateful for your help. He/she rounds in the morning with the team and again in the evening when the day’s cases are finished. He/she will be responsible for much of the didactic teaching throughout the rotation, and as such, is somebody you should befriend. There is typically not a chief resident on these services, and in those cases, the fellow is responsible for the service. Some attendings are more approachable than others, but on the whole, the attending surgeons are interested in teaching enthusiastic medical students. Accordingly, it is wise to sit down with your chief resident/fellow at the beginning of the rotation and sort out how best you can be of help to the team. In general, however, you will have the following responsibilities: Pre-Rounds: Because most services have now switched to the night float system (an intern takes overnight call for a month and pre-rounds on the service’s patients in the morning), the need for pre-rounding is mostly obsolete. Also, given the new medical student work hour restriction (see “Schedule” section below), chances are you will not be performing any of these duties. If you are unsure of whether or not your service has a night float, simply ask your chief the day before starting your rotation. Prior to morning rounds, you may be responsible for pre-rounding on a number of patients on the service. Typically, pre-rounding involves gathering the numbers (vitals, I&O’s, labs) on the patients on your service. Some chiefs/fellows would like you to wake up the patient to talk/examine them; others will just want you to collect the patients’ data.

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To determine the impact of this trial on the pooled estimate order female viagra on line amex, we added it to the meta-analysis with an assumed standard deviation equal to half the mean change in score in each treatment group buy 100mg female viagra with mastercard. The body of evidence supporting a conclusion of equivalence of oral selective antihistamine and leukotriene receptor antagonist for this outcome is therefore precise discount 100mg female viagra fast delivery. The overall strength of evidence for this conclusion is rated as moderate based on these considerations. One of these was a good quality trial of 187 patients (11 percent of patients reporting this outcome) that showed a treatment effect of 0. All other assessments favored oral selective antihistamine, including two 113, 114 109 fair quality trials of 1321 patients (77 percent of patients reporting) and one trial that was rated poor quality due to noncomparable groups at baseline and inappropriate analysis of results (unadjusted for baseline group differences). Four-week results from one trial were not included in the meta- analysis because 2-week results were the identified primary outcome. Eleven percent of patients were in the good quality trial, and 12 percent were in the poor quality trial. Although results across individual trials were inconsistent at 2 weeks, statistical heterogeneity for the pooled treatment effect was low. The body of evidence supporting a conclusion of equivalence of oral selective antihistamine and leukotriene receptor antagonist for this outcome is therefore precise. The strength of evidence for this conclusion is rated as moderate based on these considerations. All outcomes had greater improvements with leukotriene receptor antagonist than with oral selective antihistamine, but no statistically significant differences between treatment groups were 68 observed for any outcome during the 4 weeks of the trial. For all outcomes, the risk of bias was rated as low, and consistency could not be assessed with a single trial. Treatment effects at 2 and 4 weeks were: Total asthma symptoms on a 0-9 point scale: 0. For all other outcomes, evidence was insufficient to support the use of one treatment over the other. All three results favored oral selective 111-114 antihistamine over leukotriene receptor antagonist. The pooled treatment effect favored oral selective antihistamine (mean difference 0. One of two trials not included in the meta-analysis represented 6 percent of patients reporting this 109 outcome and found no treatment difference between groups at 2 weeks. The other trial, also representing 6 percent of patients reporting this outcome, showed a treatment effect of 0. One of the trials included in the meta-analysis reported 4-week results, which were not included because 2-week results were the identified primary outcome. In contrast to the 2-week result, the treatment effect at 4 weeks favored leukotriene receptor antagonist. Twenty- one percent of patients were in good quality trials, and 37 percent were in poor quality trials. Statistical heterogeneity for the pooled effect favoring oral selective antihistamine was low, and 110 one trial not included in the meta-analysis that showed a treatment difference of zero represented only 6 percent of patients reporting this outcome. One trial, a large trial representing 20 percent of patients reporting this outcome, was included in the meta-analysis of results at 2 weeks and reported an additional treatment effect of 0. Based on these considerations, the body of evidence supporting a conclusion of equivalence of oral selective antihistamine and leukotriene receptor antagonist for this outcome is therefore considered precise. Total nasal symptom score at 2 to 4 weeks: meta-analysis of 7 trials–oral selective antihistamine versus leukotriene receptor antagonist 72 Table 27. Total ocular symptom score is the mean of scores for 4 ocular symptoms (itching, tearing, redness, and puffiness) using a 0 (no symptom) to 3 (severe symptom) rating scale. Total ocular symptom score at 2 to 4 weeks: meta-analysis of 4 trials–oral selective antihistamine versus leukotriene receptor antagonist 73 Table 28. Six trials were conducted in North America, two in 116 115, 117, 120, 121 116 Europe, one in Asia. Six trials were double-blinded, one trial was open-label, 118, 119 and two were considered to have inadequate patient blinding. Trials included 50 to 895 patients randomized to treatment groups of interest and used either fluticasone propionate (six 115, 117, 118, 121 116, 119, 120 trials ) or beclomethasone (three trials ) as the intranasal corticosteroid, and 115-117, 119-121 118 azelastine (eight trials ) or olopatadine (one trial ) as the nasal antihistamine. Seven 115, 117-119, 121 116 120 trials were 2 weeks in duration, one was 4 weeks, and one was six weeks. Six 115, 117, 118, 121 116, 119, 120 trials were industry funded, and three did not report funding source. Approximately 55 percent of patients 116, 120 were female, although men were the majority in two trials. Outcomes reported were nasal 115-121 115, 117, 118 117, symptoms (nine trials ), eye symptoms (five trials ), and quality of life (two trials 121 116 ). All nine trials reported nasal symptom outcomes at 2 weeks, one at 2, 3, and 4 weeks, and 120 one at 2, 3, 4 and 5 weeks. Most trials used a 4-point scale (0 = no symptoms, 3 = severe symptoms) for the assessment of nasal symptoms. Individual nasal symptoms (congestion, rhinorrhea, and sneezing) at 3-4 weeks: Evidence was insufficient to support the use of one treatment over the other based on one trial116 with high risk of bias and an imprecise result. These results are based on trials of two of eight intranasal corticosteroids (25 percent) and both nasal antihistamines (100 percent). Synthesis and Strength of Evidence Trial level comparative outcome data for nasal symptoms can be found in Table 31, for ocular symptoms in Table 32, and for quality of life in Table 33. Nasal Symptoms 115-119, 121 Eight of nine trials assessed congestion after 2 weeks of treatment (N=2443 of 115-119 2473). Seven of these reported treatment effects favoring intranasal corticosteroid, although 121 none were reported to be statistically significant. In the eighth trial, representing 4 percent of patients reporting this outcome, the treatment difference was zero. A meta-analysis of four good quality 115, 121 trials (N=1791; 73 percent of patients reporting this outcome) yielded a statistically significant pooled effect of 0. Treatment effects 116-119 for four trials not included in the meta-analysis favored intranasal corticosteroid with a 117 116 range of 0. Treatment effects consistently favored intranasal corticosteroid in 96 percent of patients reporting on this outcome. This finding was consistent 115, 121 with results of a meta-analysis of four of these trials (73 percent of patients reporting this 121 outcome), including the one trial that reported a treatment effect of zero, and statistical heterogeneity was low. Of four 116-119 118 trials not included in the meta-analysis, one reported a treatment effect favoring intranasal corticosteroid but did not report the magnitude of the effect. Because this trial represented 5 percent of patients reporting this outcome, its impact on the pooled estimate if this 117 trial were included in the meta-analysis likely would be minimal. One trial (12 percent of patients reporting this outcome) showed a treatment effect (0.

In some patients this disease is limited to the eyes only buy female viagra discount, but in majority of cases after some time other muscles which control the functions like laughing buy female viagra master card, chewing discount female viagra 50mg without prescription, swallowing, speaking and the movement of limbs are affected and ultimately the muscles controlling the respiration function are also affected and the life of the patient is endangered. In the advanced stage of the disease or in stressful physical situations like infection or pregnancy, respiratory problems can occur. There is a recurring weakness in the muscles due to this disease, which may subside or increase in a period of time or remain as it is for a long time. Though the intensity of this disease can vary every hour in a patient and from patient to patient, at the end of the day the patient may seem weaker due to exertion and slight improvement may be seen after relaxing. This gland situated in the chest, is large in infancy, which gradually reduces in size with age, and in an adult it is almost invisible. In 10% to 15% patients a tumor of the thymus gland called thymoma is seen which is usually benign, but sometimes there may be a possibility of malignancy. Many a time it is difficult to diagnose the disease from the primary symptoms, but a specialist doctor can detect the disease from its signs and symptoms. G: The nerves are stimulated electrically, which can demonstrate the defect in their capability to conduct the impulses. Tilstigmin test : If an injection of tilstigmin gives immediate relief in the symptoms, it is considered as the confirmation of the diagnosis. Treatment : Anticholinesterase drugs like neostigmine or pyridostigmine are used in the treatment of this disease that strengthens the impulse going from the nerves to the muscles. This helps in the availability of acetylcholine for a longer period, increasing the contractibility of the muscles. This medicine is very beneficial for the patient but it does not help the patient to carry on all his activities with the strength he had before the onset of the disease. In severely afflicted patients, a treatment called Plasmapheresis is done, in which the patients own blood is transfused back after purifying it. This process removes the acetylecholine antibodies and other toxins, which cause the defect in the conduction of the impulse to the muscles. This treatment is attempted when all other treatments have failed and the patient is in serious condition. This treatment can save life of the patient in myasthenic crisis or when the disease reaches the third, fourth or last stage. Another treatment which is as effective as Plasmapheresis but extremely expensive is the Immunoglobulin therapy, in which immunoglobulin collected from the blood of healthy individuals or prepared synthetically is introduced in the patients body in very high doses. Usually a dose of 400-mgmlcg-body weight is given per day for 3-5 days The approximate expenditure of this treatment is about 1. If diagnosis is done in the early stages and treatment taken from a specialist most of the patients get relief and lives can be saved. This system consists of the large brain, small brain, spinal cord, the nerves emanating from them, the neuromuscular junction and muscles. In the previous chapter we have discussed in detail about the disease of the neuromuscular junction namely, Myasthenia Grams. Duchenne Muscular Dystrophy : This hereditary disease is a sex-linked recessive disorder of muscles related to X- chromosome which is found in about 30 per one-Iakh boys. The child falls while walking, has difficulty in getting up and climbing stairs with a gradual increase in weakness. Symptoms of this disease may be seen in other male offsprings in the family, or in mother’s brothers and their sons. Treatment : No permanent cure has yet been discovered for this disease though steroids can control the disease to some extent. Becker Muscular Dystrophy : This disease is a sex linked recessive disease linked to X- chromosome, in which the muscular weakness is similar to that of Duchenne Muscular Dystrophy, but the amount of the weakness is less and the speed of spreading of the disease is slow. The primary symptoms of the disease are seen in 5 to 15 years of age and the patient usually lives up to 4 to 5 decades. Limb Girdle Dystrophy : This muscular disorder is found in both males and females between the first and fourth decade of life. Apart from this, in facio-scapulo-humeral muscular dystrophy there is weakness of the muscles of the mouth, shoulders and hands. Congenital myopathy : The muscular disorders seen in infants include the central core, nimeline and centro nuclear myopathy. Besides this, any disorder of the main part of the cells namely mitochondria causes a congenital disease called mitochondrial myopathy. Metabolic Myopathy : Congenital metabolic disorders like glycogen storage, myophosphorylase, lipid storage, and some other mitochondrial myopathies are included in this. Periodic Paralysis : A deficiency of potassium in the blood can cause hypokalemic periodic paralysis in which the shoulder muscles and the thigh muscles weaken. Sometimes, it can also affect the muscles of the eyes as well as the respiratory muscles, which can prove fatal if not treated properly. A doctor’s supervision is very essential in this matter, because overdose or low dose of potassium can cause serious side effects. Hyperkalemic periodic paralysis : An excessive amount of potassium in the blood also causes similar type of weakness in the muscles. Paramyotonia congenita : In this disorder the muscular weakness can occur due to cold climate or without any apparent reason. We will now study in detail about the difficult diseases occurring due to the inflammation of the muscles. Polymyositis and Dermatomyositis : In these diseases, initially the process of inflammation occurs in the muscles and the muscles start becoming emaciated-wasted. The main symptom of this disease is the weakness of the muscles that gradually increases and makes the patient handicapped. Changes in the protective immune system of the body, produce cells, which destroy the cells of the muscles and hence this disease occurs. Some times it may hold back, but in most of the cases ifthe right treatment is not taken, the weakness keeps on increasing gradually. Patients suffer from pain in the muscles specially while climbing steps, getting up from the chair, raising the hand up etc. Cyclosporin: This drug helps in controlling the disease well, but in the long run the side effects of the medicine are seen. If physiotherapy is done regularly everyday, it can prevent the muscles from deteriorating to a certain extent. It is important to get immediate advice from the doctor instead of considering the problem as an ordinary pain and letting it deteriorate further. The reaction of our mind and body towards environmental and social challenges in our life is called stress. In challenging situations like competitions or exams, stress makes a person alert and strengthens the performance. In stressful situations, our body undergoes various bio chemical changes, which produce two kinds of reactions - to fight or to run away. During stress, our sympathetic nervous system gets excited, resulting in the secretion of adrenaline and nor-adrenaline from the adrenal gland causing specific reactions in the body. The muscles contract, hands and feet become cold, perspiration takes place, hair stands on ends and sometimes shivering may occur.

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The night resident should include an assessment of whether or not the patient might transfer to the floor in sign-out buy female viagra 100 mg. If urgent transfer to floor orders are needed prior to rounds beginning cheap female viagra online master card, the cross cover resident should do them generic female viagra 100 mg without a prescription. If unable to complete daily notes on all patients, prioritize medical patients over surgical patients. The provision of specialized care for children with critical illness which may best be provided by concentrating these patients in areas under the supervision of skilled and specially trained team of physicians and nurses. She supervises the nursing and administrative staff of the unit and is responsible for the day-to-day operations of the unit. If parents make a request to you that relates to nursing staffing, please inform the charge nurse. An on-going program of education in pediatric intensive care nursing has been the responsibility of the nursing service. In addition, appropriate seminars discussing subjects of pertinence in pediatric intensive care have been and will continue to be organized with physician participation. The respiratory therapy staff are responsible for setting up and maintaining the ventilators, delivering respiratory treatments, and assisting with patient care that involves respiratory care (i. The Pediatric Intensive Care Unit is available to all pediatric patients regardless of the service primarily responsible for the child. Cardiology fellows should supervise the care of cardiac surgery and cardiology patients. Emergency medicine interns and anesthesia fellows should follow patients as the primary physician. Other visitors (surgical, dental, etc) may tailor their experience to their needs. Third year students will follow patients under the supervision of one of the pediatric residents, and will have greater supervision than do the rd subinterns. There are policies in place regarding triage of surgical and medical patients that are used when beds or nurses are scarce. These policies are necessary to insure optimum care for all children who require pediatric intensive care. The intensivist is the attending of record Medical patients transported in for outside institutions. If they are immediately post or pre-operative, the primary service is Pediatric Cardiac Surgery, with medical consultation. Pediatric residents are the primary residents for the pediatric cardiac surgery patients. The degree to which the surgical services manage the medical issues of their patients will depend on the service and the patient. The degree to which the surgical services manage the medical issues of their patients will depend on the service and the patient. They should be called for anything that is needed short of immediate resuscitation. If you use a pre-printed order and want to write more things, use regular order paper. There are also pre printed orders for sedation drips, muscle relaxant drips, cardiac patient ventilator weaning. If you are unfamiliar with them, ask the intensivist or the nurse to assist in using them. These will be completed by the intensivist or the pediatric resident with attending supervision. Draw blood gases, electrolytes and hematocrit, and send these to the lab for stat results. Institute cardio-pulmonary resuscitation with Ambu bag and external cardiac massage. If an anesthesiologist is needed emergently, the pediatric on call anesthesiology number should be paged. Confirmation of the availability of a ward bed as well as an accepting physician must be made prior to transfer. Emergency medicine interns are on call nd with the cross cover 2 year pediatric resident. Prerounding, including gathering information about events of the night, vitals with I/Os, labs, and examining the patient must be accomplished prior to rounds. If you are unable to pre round on all patients, do so on the most ill or acute patients so that decisions can be made on rounds. It is helpful if the post call person gives accurate, summative sign-out so that pre-rounding is not bogged down by trying to figure out what generally happened over night. The post call person should make a quick go-around the unit prior to the day people coming in so any last minute changes can be relayed. The resident on call the previous night will pre- round on all the patients (subject to change by residents—how you do this is up to you). If both residents will be gone for a given time period, please notify the attending on service as soon as possible (i. The attendings have a backup system in place, we need to know when 2 attendings will be needed. If you are finding it difficult to comply with the regulations, please let us know. It is assumed you will be present and the attending on service will cover issues during the lecture. There will be times when the attending will do the procedures and times when a more senior resident will do the procedure. As a general rule, lines on infants or hemodynamically unstable patients will be done by the attending. It has been developed by a collaboration of Peds intensivists around the country and is used to tailor our educational objectives. Even if you aren’t a neurologist, you will likely notice something really bad that we should know about). Double Pages and Code 99 A "double page" is a page indicating the emergency need for the house officer named to respond immediately. Occurs due to an absolute or relative insulin deficiency along with an excess of counter regulatory hormones (e. Fatty acids are oxidized in liver resulting in elevated levels of circulating ketone bodies (beta-hydroxybutyrate and acetoacetate) 3. Counter regulatory hormones stimulate hepatic ketogenesis as well as gluconeogenesis and glycogenolysis resulting in excess glucose production and hyperglycemia 4. Careful history: vomiting, abdominal pain, polyuria, polydipsia, nocturia, weakness, heavy breathing or shortness of breath, symptoms of intercurrent illness, mental status changes, sweet odor to breath, weight loss 2. Physical exam: dehydration (dry mucous membranes, poor skin turgor, poor perfusion), tachycardia, hypotension, Kussmaul respirations, somnolence, hypothermia, impaired consciousness 3. Correction for psuedo/dilutional hyponatremia: Na+ (corrected) = Na+ (measured) + [(serum glucose – 100)/100] x 1.

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